Payers & enrollment
- Payers
- Transaction enrollment
Eligibility & benefits
- Eligibility checks
- Insurance discovery
- Coordination of benefits
Claims processing
- Claim submission
- Claim acknowledgments
- Remittances
- Real-time claim status
EDI platform
- Transaction
- Interchange
- File execution
- Fragments
- Mappings
- Events
Insurance Discovery Check
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1 \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"provider": {
"npi": "1999999984"
},
"subscriber": {
"firstName": "John",
"lastName": "Smith",
"middleName": "Robert",
"dateOfBirth": "19800101",
"ssn": "123456789",
"gender": "M",
"address": {
"address1": "123 Main St",
"city": "Springfield",
"state": "IL",
"postalCode": "62701"
}
},
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
}
}'{
"discoveryId": "12345678-abcd-4321-efgh-987654321abc",
"items": [
{
"provider": {
"providerName": "provider",
"entityType": "Non-Person Entity",
"npi": "1999999984"
},
"subscriber": {
"memberId": "987654321000",
"firstName": "John",
"lastName": "Doe",
"middleName": "Smith",
"gender": "M",
"dateOfBirth": "19900115",
"groupNumber": "123456-78",
"planNumber": "123456-EXMPL9876",
"groupDescription": "Individual On-Exchange",
"address": {
"address1": "123 Main Street",
"city": "ANYTOWN",
"state": "CA",
"postalCode": "12345"
}
},
"payer": {
"name": "EXAMPLE INSURANCE CO"
},
"planInformation": {
"planNumber": "123456-EXMPL9876",
"groupNumber": "123456-78",
"groupDescription": "Individual On-Exchange"
},
"planDateInformation": {
"planBegin": "20250101",
"eligibilityBegin": "20250101",
"service": "20250301"
},
"benefitsInformation": [
{
"inPlanNetworkIndicatorCode": "W",
"benefitsRelatedEntities": [
{
"entityIdentifier": "Primary Care Provider",
"entityIdentification": "XX",
"entityName": "Dough",
"entityIdentificationValue": "1234567890",
"entityFirstname": "Jane",
"entityType": "Person"
}
],
"additionalInformation": [
{
"description": "To determine if a prior authorization is required, please check the health plan's website."
}
],
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"inPlanNetworkIndicator": "Not Applicable",
"name": "Active Coverage",
"code": "1",
"planCoverage": "Gold Plan"
},
{
"serviceTypes": [
"Medical Care"
],
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "W",
"serviceTypeCodes": [
"1"
],
"inPlanNetworkIndicator": "Not Applicable",
"code": "1"
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "Y",
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan"
},
{
"inPlanNetworkIndicator": "Yes",
"code": "A",
"serviceTypeCodes": [
"4"
],
"name": "Co-Insurance",
"coverageLevel": "Family",
"serviceTypes": [
"Diagnostic X-Ray"
],
"inPlanNetworkIndicatorCode": "Y",
"benefitPercent": "0.5",
"planCoverage": "Gold Plan",
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"coverageLevelCode": "FAM"
},
{
"name": "Non-Covered",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"code": "I"
},
{
"code": "1",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Diagnostic Lab"
],
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"serviceTypeCodes": [
"5"
]
},
{
"code": "B",
"name": "Co-Payment",
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"coverageLevelCode": "FAM",
"benefitAmount": "20",
"coverageLevel": "Family",
"serviceTypeCodes": [
"5"
],
"serviceTypes": [
"Diagnostic Lab"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "per visit"
}
]
},
{
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"5"
],
"name": "Non-Covered",
"code": "I",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Diagnostic Lab"
]
},
{
"serviceTypeCodes": [
"12"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1"
},
{
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"code": "A",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"serviceTypeCodes": [
"12"
]
},
{
"name": "Non-Covered",
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"12"
]
},
{
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"code": "1",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"serviceTypeCodes": [
"13"
]
},
{
"coverageLevel": "Family",
"inPlanNetworkIndicator": "Yes",
"benefitPercent": "0.5",
"timeQualifier": "Visit",
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"code": "A",
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"13"
],
"timeQualifierCode": "27",
"name": "Co-Insurance",
"inPlanNetworkIndicatorCode": "Y"
},
{
"inPlanNetworkIndicator": "No",
"code": "I",
"name": "Non-Covered",
"serviceTypeCodes": [
"13"
],
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N"
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"18"
],
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"code": "1",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Durable Medical Equipment Rental"
]
},
{
"serviceTypes": [
"Durable Medical Equipment Rental"
],
"serviceTypeCodes": [
"18"
],
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"coverageLevel": "Family",
"inPlanNetworkIndicatorCode": "Y",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"benefitPercent": "0.5",
"timeQualifierCode": "27",
"coverageLevelCode": "FAM"
},
{
"serviceTypeCodes": [
"18"
],
"serviceTypes": [
"Durable Medical Equipment Rental"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"code": "I",
"name": "Non-Covered"
},
{
"serviceTypeCodes": [
"33"
],
"serviceTypes": [
"Chiropractic"
],
"planCoverage": "Gold Plan",
"additionalInformation": [
{
"description": "Limited to 26 visits per year (visits in excess of 26 require prior authorization)."
}
],
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"code": "1"
},
{
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"timeQualifierCode": "27",
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"code": "A",
"name": "Co-Insurance",
"serviceTypes": [
"Chiropractic"
],
"serviceTypeCodes": [
"33"
],
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevelCode": "FAM"
},
{
"planCoverage": "Gold Plan",
"serviceTypes": [
"Chiropractic"
],
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"code": "I",
"serviceTypeCodes": [
"33"
]
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"48"
],
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"serviceTypes": [
"Hospital - Inpatient"
],
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan"
},
{
"code": "A",
"coverageLevel": "Family",
"benefitPercent": "0.5",
"timeQualifierCode": "27",
"name": "Co-Insurance",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypes": [
"Hospital - Inpatient"
],
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"48"
]
},
{
"serviceTypeCodes": [
"48"
],
"serviceTypes": [
"Hospital - Inpatient"
],
"code": "I",
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No"
},
{
"serviceTypes": [
"Hospital - Outpatient"
],
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"serviceTypeCodes": [
"50"
]
},
{
"timeQualifier": "Visit",
"coverageLevelCode": "FAM",
"code": "A",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"serviceTypeCodes": [
"50"
],
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"benefitPercent": "0.5",
"serviceTypes": [
"Hospital - Outpatient"
],
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27"
},
{
"serviceTypeCodes": [
"50"
],
"serviceTypes": [
"Hospital - Outpatient"
],
"planCoverage": "Gold Plan",
"code": "I",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered"
},
{
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"51"
],
"serviceTypes": [
"Hospital - Emergency Accident"
],
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"name": "Active Coverage"
},
{
"timeQualifierCode": "27",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"serviceTypeCodes": [
"51"
],
"timeQualifier": "Visit",
"serviceTypes": [
"Hospital - Emergency Accident"
],
"benefitPercent": "0.5",
"code": "A",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM"
},
{
"planCoverage": "Gold Plan",
"serviceTypes": [
"Hospital - Emergency Accident"
],
"code": "1",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"51"
]
},
{
"coverageLevel": "Family",
"code": "A",
"benefitPercent": "0.5",
"serviceTypeCodes": [
"51"
],
"planCoverage": "Gold Plan",
"timeQualifierCode": "27",
"name": "Co-Insurance",
"serviceTypes": [
"Hospital - Emergency Accident"
],
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "N"
},
{
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"code": "1",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"serviceTypes": [
"Hospital - Emergency Medical"
],
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"52"
],
"inPlanNetworkIndicator": "Yes"
},
{
"inPlanNetworkIndicatorCode": "Y",
"timeQualifier": "Visit",
"benefitPercent": "0.5",
"serviceTypes": [
"Hospital - Emergency Medical"
],
"code": "A",
"serviceTypeCodes": [
"52"
],
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"timeQualifierCode": "27",
"coverageLevel": "Family",
"inPlanNetworkIndicator": "Yes"
},
{
"serviceTypes": [
"Hospital - Emergency Medical"
],
"serviceTypeCodes": [
"52"
],
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "N",
"code": "1"
},
{
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"serviceTypeCodes": [
"52"
],
"serviceTypes": [
"Hospital - Emergency Medical"
],
"code": "A",
"planCoverage": "Gold Plan",
"benefitPercent": "0.5"
},
{
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"code": "1",
"serviceTypes": [
"Hospital - Ambulatory Surgical"
]
},
{
"timeQualifier": "Visit",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"coverageLevelCode": "FAM",
"benefitPercent": "0.5",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"serviceTypes": [
"Hospital - Ambulatory Surgical"
],
"code": "A",
"name": "Co-Insurance"
},
{
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"serviceTypeCodes": [
"53"
],
"code": "I",
"serviceTypes": [
"Hospital - Ambulatory Surgical"
]
},
{
"serviceTypeCodes": [
"62"
],
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"MRI/CAT Scan"
],
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1"
},
{
"timeQualifierCode": "27",
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"serviceTypes": [
"MRI/CAT Scan"
],
"serviceTypeCodes": [
"62"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"timeQualifier": "Visit"
},
{
"serviceTypes": [
"MRI/CAT Scan"
],
"serviceTypeCodes": [
"62"
],
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered"
},
{
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"code": "1",
"serviceTypeCodes": [
"65"
],
"serviceTypes": [
"Newborn Care"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
]
},
{
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"benefitPercent": "0.5",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevelCode": "FAM",
"serviceTypes": [
"Newborn Care"
],
"coverageLevel": "Family",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"name": "Co-Insurance"
},
{
"name": "Non-Covered",
"code": "I",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"serviceTypes": [
"Newborn Care"
]
},
{
"planCoverage": "Gold Plan",
"code": "1",
"serviceTypes": [
"Well Baby Care"
],
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Covered in accordance with ACA guidelines."
}
],
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"68"
]
},
{
"code": "B",
"serviceTypes": [
"Well Baby Care"
],
"benefitAmount": "0",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"68"
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"name": "Co-Payment"
},
{
"serviceTypeCodes": [
"68"
],
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"code": "I",
"serviceTypes": [
"Well Baby Care"
],
"planCoverage": "Gold Plan"
},
{
"serviceTypeCodes": [
"69"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"code": "1",
"serviceTypes": [
"Maternity"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes"
},
{
"serviceTypeCodes": [
"69"
],
"benefitPercent": "0.5",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"serviceTypes": [
"Maternity"
],
"timeQualifier": "Visit",
"coverageLevel": "Family",
"name": "Co-Insurance",
"timeQualifierCode": "27"
},
{
"serviceTypeCodes": [
"69"
],
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"serviceTypes": [
"Maternity"
]
},
{
"code": "1",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"86"
],
"name": "Active Coverage",
"serviceTypes": [
"Emergency Services"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"86"
],
"coverageLevel": "Family",
"timeQualifierCode": "27",
"serviceTypes": [
"Emergency Services"
],
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"timeQualifier": "Visit"
},
{
"inPlanNetworkIndicator": "No",
"code": "1",
"name": "Active Coverage",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"86"
],
"inPlanNetworkIndicatorCode": "N",
"serviceTypes": [
"Emergency Services"
]
},
{
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"code": "A",
"serviceTypeCodes": [
"86"
],
"serviceTypes": [
"Emergency Services"
],
"timeQualifier": "Visit",
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "N",
"timeQualifierCode": "27",
"inPlanNetworkIndicator": "No",
"name": "Co-Insurance",
"planCoverage": "Gold Plan"
},
{
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"serviceTypes": [
"Pharmacy"
],
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"88"
],
"code": "1",
"planCoverage": "Gold Plan"
},
{
"serviceTypeCodes": [
"88"
],
"coverageLevel": "Family",
"name": "Co-Payment",
"serviceTypes": [
"Pharmacy"
],
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"timeQualifierCode": "27",
"code": "B",
"benefitAmount": "10",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"additionalInformation": [
{
"description": "per prescription"
}
]
},
{
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"serviceTypeCodes": [
"88"
],
"inPlanNetworkIndicator": "No",
"code": "I",
"serviceTypes": [
"Pharmacy"
],
"planCoverage": "Gold Plan"
},
{
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"code": "1",
"serviceTypeCodes": [
"98"
],
"additionalInformation": [
{
"description": "PCP"
}
],
"name": "Active Coverage"
},
{
"additionalInformation": [
{
"description": "per visit"
},
{
"description": "PCP"
}
],
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevelCode": "FAM",
"timeQualifierCode": "27",
"serviceTypeCodes": [
"98"
],
"benefitAmount": "15",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"timeQualifier": "Visit",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"code": "B"
},
{
"code": "I",
"serviceTypeCodes": [
"98"
],
"planCoverage": "Gold Plan",
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "PCP"
}
]
},
{
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"additionalInformation": [
{
"description": "Specialist"
},
{
"description": "Covered No Limit."
}
],
"code": "1",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"98"
]
},
{
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "per visit"
},
{
"description": "Specialist"
}
],
"benefitAmount": "30",
"coverageLevel": "Family",
"code": "B",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"timeQualifierCode": "27",
"coverageLevelCode": "FAM",
"name": "Co-Payment",
"serviceTypeCodes": [
"98"
]
},
{
"additionalInformation": [
{
"description": "Specialist"
}
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"98"
],
"planCoverage": "Gold Plan",
"code": "I",
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N"
},
{
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"A4"
],
"planCoverage": "Gold Plan",
"code": "1",
"serviceTypes": [
"Psychiatric"
],
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit. (Primary Care Provider (PCP) and other practitioner office visits do not require prior authorization.) Note| Services (excluding Emergency Room Care / Emergency Services) rendered by an out-of-network provider"
}
]
},
{
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"serviceTypes": [
"Psychiatric"
],
"timeQualifierCode": "27",
"name": "Co-Insurance",
"serviceTypeCodes": [
"A4"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"code": "A"
},
{
"serviceTypeCodes": [
"A4"
],
"name": "Non-Covered",
"serviceTypes": [
"Psychiatric"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"inPlanNetworkIndicator": "No"
},
{
"name": "Active Coverage",
"code": "1",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
],
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes"
},
{
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"benefitPercent": "0.5",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"coverageLevelCode": "FAM",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
],
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"code": "A"
},
{
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"planCoverage": "Gold Plan",
"name": "Non-Covered",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
]
},
{
"planCoverage": "Gold Plan",
"code": "1",
"serviceTypes": [
"Psychiatric - Inpatient"
],
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"A7"
],
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage"
},
{
"timeQualifier": "Visit",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A7"
],
"timeQualifierCode": "27",
"name": "Co-Insurance",
"code": "A",
"serviceTypes": [
"Psychiatric - Inpatient"
],
"benefitPercent": "0.5"
},
{
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"A7"
],
"serviceTypes": [
"Psychiatric - Inpatient"
],
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N"
},
{
"code": "1",
"serviceTypes": [
"Psychiatric - Outpatient"
],
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A8"
],
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y"
},
{
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"serviceTypeCodes": [
"A8"
],
"benefitPercent": "0.5",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Psychiatric - Outpatient"
]
},
{
"serviceTypes": [
"Psychiatric - Outpatient"
],
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"serviceTypeCodes": [
"A8"
],
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N"
},
{
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"code": "1"
},
{
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"AD"
],
"planCoverage": "Gold Plan",
"coverageLevel": "Family",
"timeQualifierCode": "27",
"serviceTypes": [
"Occupational Therapy"
],
"code": "A",
"timeQualifier": "Visit",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicatorCode": "Y",
"benefitPercent": "0.5",
"name": "Co-Insurance"
},
{
"code": "I",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
],
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Speech Therapy"
],
"serviceTypeCodes": [
"AF"
],
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y"
},
{
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"coverageLevel": "Family",
"serviceTypeCodes": [
"AF"
],
"coverageLevelCode": "FAM",
"serviceTypes": [
"Speech Therapy"
],
"code": "A",
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y"
},
{
"planCoverage": "Gold Plan",
"name": "Non-Covered",
"code": "I",
"serviceTypeCodes": [
"AF"
],
"serviceTypes": [
"Speech Therapy"
],
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"serviceTypeCodes": [
"AG"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Limited to 150 days per year."
}
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"code": "1",
"name": "Active Coverage",
"serviceTypes": [
"Skilled Nursing Care"
],
"inPlanNetworkIndicatorCode": "Y"
},
{
"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
],
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"coverageLevelCode": "FAM",
"code": "A",
"coverageLevel": "Family",
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"timeQualifier": "Visit"
},
{
"inPlanNetworkIndicatorCode": "N",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
],
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"code": "I"
},
{
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Physician Visit - Office: Well"
],
"serviceTypeCodes": [
"BZ"
],
"planCoverage": "Gold Plan",
"additionalInformation": [
{
"description": "Covered in accordance with ACA guidelines."
}
],
"code": "1"
},
{
"coverageLevelCode": "FAM",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"BZ"
],
"inPlanNetworkIndicator": "Yes",
"name": "Co-Payment",
"coverageLevel": "Family",
"timeQualifierCode": "27",
"code": "B",
"serviceTypes": [
"Physician Visit - Office: Well"
],
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"benefitAmount": "0"
},
{
"serviceTypes": [
"Physician Visit - Office: Well"
],
"code": "I",
"serviceTypeCodes": [
"BZ"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"inPlanNetworkIndicator": "No"
},
{
"code": "1",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"serviceTypes": [
"Mental Health"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"serviceTypeCodes": [
"MH"
]
},
{
"serviceTypeCodes": [
"MH"
],
"code": "A",
"serviceTypes": [
"Mental Health"
],
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"benefitPercent": "0.5",
"name": "Co-Insurance",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"timeQualifierCode": "27"
},
{
"inPlanNetworkIndicator": "No",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Mental Health"
],
"name": "Non-Covered",
"code": "I",
"serviceTypeCodes": [
"MH"
],
"inPlanNetworkIndicatorCode": "N"
},
{
"code": "1",
"serviceTypes": [
"Physical Therapy"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"serviceTypeCodes": [
"PT"
]
},
{
"additionalInformation": [
{
"description": "per visit"
}
],
"name": "Co-Payment",
"timeQualifierCode": "27",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"coverageLevelCode": "FAM",
"benefitAmount": "15",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"code": "B",
"serviceTypeCodes": [
"PT"
],
"serviceTypes": [
"Physical Therapy"
],
"timeQualifier": "Visit"
},
{
"serviceTypeCodes": [
"PT"
],
"name": "Non-Covered",
"serviceTypes": [
"Physical Therapy"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"code": "I",
"inPlanNetworkIndicatorCode": "N"
},
{
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
],
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"planCoverage": "Gold Plan"
},
{
"serviceTypes": [
"Urgent Care"
],
"timeQualifierCode": "27",
"serviceTypeCodes": [
"UC"
],
"coverageLevelCode": "FAM",
"timeQualifier": "Visit",
"benefitAmount": "10",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"coverageLevel": "Family",
"additionalInformation": [
{
"description": "per visit"
}
],
"code": "B",
"inPlanNetworkIndicator": "Yes"
},
{
"name": "Active Coverage",
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"inPlanNetworkIndicator": "No",
"code": "1"
},
{
"benefitAmount": "10",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "per visit"
}
],
"code": "B",
"inPlanNetworkIndicatorCode": "N",
"timeQualifier": "Visit",
"serviceTypeCodes": [
"UC"
],
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"name": "Co-Payment",
"serviceTypes": [
"Urgent Care"
],
"coverageLevel": "Family",
"timeQualifierCode": "27"
},
{
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "0",
"code": "C",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"name": "Deductible",
"code": "C",
"timeQualifierCode": "29",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"timeQualifier": "Remaining",
"benefitAmount": "0",
"inPlanNetworkIndicatorCode": "Y"
},
{
"coverageLevelCode": "FAM",
"name": "Deductible",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"coverageLevel": "Family",
"inPlanNetworkIndicatorCode": "Y",
"timeQualifier": "Calendar Year",
"benefitAmount": "0",
"serviceTypeCodes": [
"30"
],
"code": "C",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "23",
"planCoverage": "Gold Plan"
},
{
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"30"
],
"code": "C",
"name": "Deductible",
"timeQualifierCode": "29",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"planCoverage": "Gold Plan",
"coverageLevelCode": "FAM",
"timeQualifier": "Remaining",
"coverageLevel": "Family",
"benefitAmount": "0"
},
{
"serviceTypeCodes": [
"30"
],
"name": "Deductible",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"coverageLevelCode": "IND",
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"coverageLevel": "Individual",
"code": "C",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"inPlanNetworkIndicatorCode": "N",
"benefitAmount": "0"
},
{
"timeQualifierCode": "29",
"benefitAmount": "0",
"name": "Deductible",
"coverageLevel": "Individual",
"planCoverage": "Gold Plan",
"code": "C",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"timeQualifier": "Remaining",
"coverageLevelCode": "IND",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"benefitAmount": "0",
"inPlanNetworkIndicatorCode": "N",
"coverageLevelCode": "FAM",
"code": "C",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"timeQualifierCode": "23",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"timeQualifier": "Calendar Year",
"coverageLevel": "Family"
},
{
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"timeQualifierCode": "29",
"benefitAmount": "0",
"inPlanNetworkIndicatorCode": "N",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"name": "Deductible",
"inPlanNetworkIndicator": "No",
"coverageLevelCode": "FAM",
"timeQualifier": "Remaining",
"planCoverage": "Gold Plan",
"code": "C"
},
{
"coverageLevel": "Individual",
"inPlanNetworkIndicator": "Yes",
"benefitAmount": "3000",
"name": "Out of Pocket (Stop Loss)",
"serviceTypeCodes": [
"30"
],
"planCoverage": "Gold Plan",
"timeQualifier": "Calendar Year",
"code": "G",
"timeQualifierCode": "23",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"coverageLevelCode": "IND"
},
{
"code": "G",
"coverageLevel": "Individual",
"timeQualifier": "Remaining",
"planCoverage": "Gold Plan",
"name": "Out of Pocket (Stop Loss)",
"timeQualifierCode": "29",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"30"
],
"benefitAmount": "2000",
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"inPlanNetworkIndicatorCode": "Y",
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23",
"benefitAmount": "6000",
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family"
},
{
"code": "G",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"benefitAmount": "5000",
"timeQualifierCode": "29",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"timeQualifier": "Remaining"
},
{
"coverageLevelCode": "IND",
"benefitAmount": "0",
"serviceTypeCodes": [
"30"
],
"timeQualifier": "Calendar Year",
"planCoverage": "Gold Plan",
"name": "Out of Pocket (Stop Loss)",
"code": "G",
"coverageLevel": "Individual",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"benefitAmount": "0",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"code": "G",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"coverageLevelCode": "IND",
"name": "Out of Pocket (Stop Loss)",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"planCoverage": "Gold Plan"
},
{
"code": "G",
"inPlanNetworkIndicator": "No",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"inPlanNetworkIndicatorCode": "N",
"benefitAmount": "0",
"timeQualifier": "Calendar Year",
"coverageLevel": "Family",
"name": "Out of Pocket (Stop Loss)",
"serviceTypeCodes": [
"30"
],
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan"
},
{
"benefitAmount": "0",
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"planCoverage": "Gold Plan",
"name": "Out of Pocket (Stop Loss)",
"inPlanNetworkIndicator": "No",
"code": "G",
"inPlanNetworkIndicatorCode": "N",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"coverageLevelCode": "FAM"
}
],
"confidence": {
"level": "REVIEW_NEEDED",
"reason": "This record was identified as a low confidence match due to a DOB partial match"
}
}
],
"meta": {
"applicationMode": "production",
"traceId": "1-abcdef12-123456789abcdef123456789"
},
"status": "COMPLETE"
}This endpoint submits an insurance discovery check request for a patient. You can use an insurance discovery check to find a patient’s active coverage using only their demographic data.
You may need to perform an insurance discovery check when a patient provides outdated insurance details, doesn’t have their insurance card, or can’t provide insurance details in an urgent care situation. You may also want to use insurance discovery checks to simplify patient onboarding by reducing the amount of information new patients must provide to schedule an appointment.
- Call this endpoint with as much patient demographic information as possible to increase the chances of finding matching coverage. You’ll also need to include information like the provider’s NPI and the service date, similar to an eligibility check.
- Stedi determines if the patient has active coverage with one or more payers. This process involves demographic lookups to enrich partial patient details, comparisons across third-party data sources to determine member IDs, and submitting real-time eligibility checks to payers to detect coverage.
- When the insurance discovery check is complete, Stedi returns an array of potential active coverages along with subscriber details and benefits information.
You should always review the results to ensure the returned subscriber information for each active health plan matches the demographic information for the patient. Once you confirm matching coverage, you can use the benefits information to determine the patient’s eligibility for services. You generally shouldn’t need to perform a follow-up eligibility check since the insurance discovery response includes the same benefits information as a standard eligibility check.
Enrollment requirements
You should submit a transaction enrollment request for each provider for whom you plan to submit insurance discovery checks. To enroll your providers, please download the enrollment spreadsheet template and add one row for each provider. You’ll be required to provide the following information:
- National Provider Identifier (NPI)
- Tax Identification Number (TIN)
- Medicaid Provider ID (if applicable)
You can email the completed template to enrollments@stedi.com, or drop it in your shared Slack channel.
Response
This endpoint can take up to 120 seconds to return a response, though it’s often faster.
The response can have one of two status values:
COMPLETE- Stedi has completed the insurance discovery search for the patient. If Stedi finds coverage for the patient, theitemsarray will contain the results. If Stedi doesn’t find any coverage for the patient, theitemsarray will be empty.PENDING- Stedi is still processing the insurance discovery search for the patient. You can use thediscoveryIdin the response to retrieve the results asynchronously.
Retrieve results asynchronously
If the synchronous insurance discovery response indicates that the search is still PENDING, you can use the discoveryId to retrieve the complete results asynchronously from the Insurance Discovery Check Results endpoint.
Authorizations
A Stedi API Key for authentication.
Body
Information about the provider requesting the insurance discovery check.
The provider's National Provider Identifier (NPI).
10 - 15Demographic information for the patient when they are the health plan subscriber.
We strongly recommend providing as much information as possible to improve the probability of finding matching coverage. We especially recommend providing the subscriber's Social Security Number and their address - particularly their zip code.
The subscriber's first name.
1 - 25The subscriber's last name.
1 - 25The subscriber's middle name or initial.
1 - 25The subscriber's date of birth (DOB), formatted as YYYYMMDD.
The subscriber's Social Security Number (SSN). We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
1 - 11The subscriber's gender. This can be set to either M - Male or F - Female.
M, F The subscriber's address. We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Demographic information for the patient when they are a dependent on a health plan.
- We strongly recommend providing as much information as possible to improve the probability of finding matching coverage. We especially recommend providing the dependent's Social Security Number and their address - particularly their zip code.
- You should provide information for both the subscriber and the dependent in the request when possible.
- If you only have the dependent's information, you should identify them in the
subscriberobject instead and leave this object empty. Note that some payers require information about both the dependent and the subscriber, so providing only the dependent's information limits Stedi's ability to return coverage matches for those payers.
The dependent's first name.
1 - 25The dependent's last name.
1 - 25The dependent's middle name or initial.
1 - 25The dependent's date of birth (DOB), formatted as YYYYMMDD.
The dependent's Social Security Number (SSN). We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
1 - 11The dependent's gender. This can be set to either M - Male or F - Female.
M, F The dependent's address. We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3The date range for the service being requested. If you don't specify a service date (either a single day or a range of dates), Stedi defaults to the current date.
You can specify either a single dateOfService or a beginningDateOfService and endDateOfService.
The beginning date, formatted as YYYYMMDD.
The end date, formatted as YYYYMMDD. If you don't specify an end date, Stedi defaults to the same date as beginningDateOfService.
The date of service, formatted as YYYYMMDD. You can use this value to specify a single occasion. If you don't specify a service date (either a single day or a range of dates), Stedi defaults to the current date.
Response
A unique ID for this insurance discovery check. You can use it to retrieve the results asynchronously through the Insurance Discovery Check Results endpoint.
The status of the discovery check. This is either PENDING or COMPLETE.
- If the status is COMPLETE, the items array will contain any potential coverage matches Stedi found for the patient.
- If the status is PENDING, the check is still in progress. You can immediately begin polling the Insurance Discovery Check Results endpoint to retrieve the results asynchronously.
PENDING, COMPLETE An array of potential coverage matches for the patient. This will only be populated if the insurance discovery check status is COMPLETE. Each item in the array contains information about a potential match, including the provider, subscriber, payer, and plan information.
Information about the provider who requested the insurance discovery check.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider.
Provider, Third-Party Administrator, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, Payer, Unknown The type of entity.
Person, Non-Person Entity The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The Health Care Provider Taxonomy Code.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The provider's contact information.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Information about the subscriber for this coverage. You should always review this information to ensure that the coverage Stedi found is a match for the patient.
Information about the patient's healthcare diagnosis.
The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The member ID for the subscriber's insurance policy.
The subscriber's first name.
The subscriber's last name.
The subscriber's middle name or initial.
The name suffix, such as Jr., Sr., or III.
Code indicating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the subscriber.
Insured or Subscriber The entity type for the subscriber. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Person, Non-Person Entity The subscriber's unique health identifier.
The subscriber's date of birth, formatted as YYYYMMDD.
The status of the subscriber's information, used to report military service data.
A, C, L, O, P, S, T, Unknown The subscriber's employment status code, used to report military service data.
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU, Unknown The subscriber's government service affiliation code, used to report military service data.
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W, Unknown Context that identifies the exact military unit. Used to report military service data.
The subscriber's military service rank code.
A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, C6, C7, C8, C9, E1, F1, F2, F3, F4, G1, G4, L1, L2, L3, L4, L5, L6, M1, M2, M3, M4, M5, M6, P1, P2, P3, P4, P5, R1, R2, S1, S2, S3, S4, S5, S6, S7, S8, S9, SA, SB, SC, T1, V1, W1, Unknown The format of the military service date and time period.
D8, RD8 The military service date, formatted as YYYYMMDD.
The military service start date, formatted as YYYYMMDD.
The military service end date, formatted as YYYYMMDD.
The subscriber's Social Security Number (SSN).
The group number associated with the subscriber's insurance policy.
The plan number associated with the subscriber's insurance policy.
The network identification number associated with the subscriber's insurance policy.
Group name
Plan name
Plan network name
The name of the relationToSubscriberCode. For the subscriber, this is always Self.
Self For the subscriber, this is always 18 for Self.
18 Indicates the status of the insured. For the subscriber, this is always Y.
Y The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. This is always 001
001 Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
25 The number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider.
Provider, Third-Party Administrator, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, Payer, Unknown The type of entity.
Person, Non-Person Entity The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The Health Care Provider Taxonomy Code.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The provider's contact information.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Deprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
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
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 41, 43, 44, 45, 46, 47, 48, 50, 51, 79, 97, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly Information about the dependent for this coverage. You should always review this information to ensure that the coverage Stedi found is a match for the patient.
Information about the patient's healthcare diagnosis.
The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The member ID for the subscriber's insurance policy.
The dependent's first name.
The dependent's last name.
The dependent's middle name or initial.
The name suffix, such as Jr., Sr., or III.
Code indicating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the dependent.
Dependent The entity type for the dependent. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Person, Non-Person Entity The dependent's unique health identifier.
The dependent's date of birth, formatted as YYYYMMDD.
The status of the dependent's information, used to report military service data.
A, C, L, O, P, S, T, Unknown The dependent's employment status code, used to report military service data.
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU, Unknown The dependent's government service affiliation code, used to report military service data.
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W, Unknown Context that identifies the exact military unit. Used to report military service data.
The dependent's military service rank code.
A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, C6, C7, C8, C9, E1, F1, F2, F3, F4, G1, G4, L1, L2, L3, L4, L5, L6, M1, M2, M3, M4, M5, M6, P1, P2, P3, P4, P5, R1, R2, S1, S2, S3, S4, S5, S6, S7, S8, S9, SA, SB, SC, T1, V1, W1, Unknown The format of the military service date and time period.
D8, RD8 The military service date, formatted as YYYYMMDD.
The military service start date, formatted as YYYYMMDD.
The military service end date, formatted as YYYYMMDD.
The dependent's Social Security Number (SSN).
The group number associated with the subscriber's insurance policy.
The plan number associated with the subscriber's insurance policy.
The network identification number associated with the subscriber's insurance policy.
Group name
Plan name
Plan network name
The name of the relationToSubscriberCode. For example, Child when the code is 19.
Spouse, Child, Employee, Unknown, Organ Donor, Cadaver Donor, Life Partner, Other Relationship For the dependent, this can be 01 - Spouse, 19 - Child, 20 Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
01, 19, 20, 21, 39, 40, 53, G8, Unknown Indicates the status of the insured. For the dependent, this is always N.
N The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. This is always 001
001 Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
25 The number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider.
Provider, Third-Party Administrator, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, Payer, Unknown The type of entity.
Person, Non-Person Entity The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The Health Care Provider Taxonomy Code.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The provider's contact information.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Deprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
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
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 41, 43, 44, 45, 46, 47, 48, 50, 51, 79, 97, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly Information about the payer for this coverage. Note that payer names and IDs aren't normalized, so you'll need to handle matching these results to Stedi's Payer Network or your own internal payer list.
The entity identifier code for the payer.
Third-Party Administrator, Employer, Gateway Provider, Plan Sponsor, Payer The entity type qualifier for the payer. Can be set to Person (not commonly used) or Non-Person Entity (most common).
Person, Non-Person Entity The payer's first name, when the payer is an individual (not commonly used).
The payer's last name. Used when the payer is an individual (not commonly used).
The payer's business name, when the payer is not a person.
The payer's middle name or initial, when the payer is an individual (not commonly used).
The payer's name suffix, such as Jr. or III. Used when the payer is an individual (not commonly used).
The payer's federal taxpayer's identification number.
The payer's National Association of Insurance Commissioners (NAIC) identification number.
The payer's National Provider Identifier (NPI).
The payer's Centers for Medicare and Medicaid Services PlanID.
The payor identification.
The payer's contact information.
Note that when contacts.communicationMode is set to UR, the communicationNumber property may not contain a valid URL. Most payers provide a partial web address for their provider portal, or something similar, such as www.example.com/portal. You must add the appropriate scheme and separators, such as https:// or http://, to make it a valid URL.
The name of the contact person.
The contact information.
Contacts
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
The communication number referenced in communicationMode. It includes the country or area code when applicable.
Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
The payer's Electronic Transmitter Identification Number (ETIN).
Additional identification for the patient's health plan.
The state license number
The Medicare provider number
The Medicaid provider number
The facility ID number
The personal identification number (PIN)
The plan number
The plan description
The group or policy number
The member identification number - only used when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The case number
The family unit number
The group number
The group description
The referral number
The alternative list ID - identifies a list of alternative drugs with the associated formulary status for the patient.
The class of contract code - used to identify the applicable class of contract for claims processing.
The coverage list ID - identifies a list of drugs that have coverage limitations for the patient.
The contract number of a contract between the payer and the provider that requested the eligibility check.
The medical record identification number
The electronic device pin number
The submitter identification number
The patient account number. If you included this value in the original eligibility request, the payer will return the same value here in the response.
The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.
The drug formulary number
The prior authorization number
The identification card serial number. The Identification Card Serial Number uniquely identifies the identification card when multiple cards have been or will be issued to a member, such as a replacement card.
The identity card number, used when the Identity Card Number is different than the Member Identification Number.
The National Provider Identifier (NPI) assigned by the Centers for Medicare and Medicaid Services
The issue number
The insurance policy number
The user identification
The medical assistance category
The eligibility category
The plan network identification number
The plan, group, or plan network name
The facility network identification number
The Medicaid recipient identification number
The prior identifier number
The social security number
The federal taxpayer's identification number
The agency claim number, only used when the information source is a Property and Casualty payer.
Contains the dates associated with coverage for this health plan. This information can help you determine the patient's eligibility for benefits.
- All dates are formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges).
- Properties contain a single date unless otherwise noted.
- Most payers return either plan or planBegin and planEnd, but the exact dates returned depend on the payer's discretion and the specific health plan.
- If the date of service is after the earliest ending plan, eligibility, planEnd, eligibilityEnd, policyEffective, or policyExpiration value, the patient likely doesn't have active coverage.
The discharge date. Single date (YYYYMMDD).
The issue date. Single date (YYYYMMDD).
The effective date of change. Single date (YYYYMMDD).
Plan effective dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
Plan eligibility dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
Added date. Payers may return this information in the case of retroactive eligibility. Single date (YYYYMMDD).
The date when COBRA coverage begins. Single date (YYYYMMDD).
The date when COBRA coverage ends. Single date (YYYYMMDD).
The start of the period when the plan premium was paid in full. Single date (YYYYMMDD).
The end of period when the plan premium payments are up-to-date. Single date (YYYYMMDD).
The date coverage from the plan begins. Single date (YYYYMMDD).
The date coverage from the plan ends. Single date (YYYYMMDD).
The date when the patient is first eligible for benefits under the plan. Single date (YYYYMMDD).
The date when the patient is no longer eligible for benefits under the plan. Single date (YYYYMMDD).
The date when the patient is enrolled in the plan. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
The admission date or dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
The date of death. Payers may return this information in the case of a deceased subscriber or dependent. Single date (YYYYMMDD).
The certification date. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
The service date or dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
The date when the policy becomes effective. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).
The date when the policy expires. Single date (YYYYMMDD).
The date when the plan information was last updated. Single date (YYYYMMDD).
The status date. Single date (YYYYMMDD).
Information about the patient's healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, copays, etc.), out of pocket maximums, and more. This is the same information you would get from a standard eligibility check.
Payers typically return at least the following properties: code, coverageLevelCode, serviceTypeCodes, and either benefitAmount or benefitPercent. However, the exact properties returned in this object are up to the payer's discretion.
Visit Determine patient benefits in our eligibility check documentation for more information about benefit types, details about how to interpret the response, and additional examples.
The code indicating the type of benefits information. Visit Eligibility and benefit codes for more information.
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y, Unknown The full name of the benefits information code.
Active Coverage, Active - Full Risk Capitation, Active - Services Capitated, Active - Services Capitated to Primary Care Physician, Active - Pending Investigation, Inactive, Inactive - Pending Eligibility Update, Inactive - Pending Investigation, Co-Insurance, Co-Payment, Deductible, Coverage Basis, Benefit Description, Exclusions, Limitations, Out of Pocket (Stop Loss), Unlimited, Non-Covered, Cost Containment, Reserve, Primary Care Provider, Pre-existing Condition, Managed Care Coordinator, Services Restricted to Following Provider, Not Deemed a Medical Necessity, Benefit Disclaimer, Second Surgical Opinion Required, Other or Additional Payor, Prior Year(s) History, Card(s) Reported Lost/Stolen, Contact Following Entity for Eligibility or Benefit Information, Cannot Process, Other Source of Data, Health Care Facility, Spend Down, Unknown Code indicating the level of coverage for the patient.
This will either be CHD - Children Only, DEP - Dependents Only, ECH - Employee and Children, EMP - Employee Only, ESP - Employee and Spouse, FAM - Family, IND - Individual, SPC - Spouse and Children, SPO - Spouse Only, or Unknown.
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO, Unknown The full name of the coverage level code.
Children Only, Dependents Only, Employee and Children, Employee Only, Employee and Spouse, Family, Individual, Spouse and Children, Spouse Only, Unknown Codes identifying the type of services. For example, 7 - Anesthesia. Visit Service Type Codes for a complete list.
Note that the word physician in service type codes refers to any healthcare provider, including physician assistants, nurse practitioners, and other types of healthcare professionals.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, NI, ON, PT, PU, RN, RT, TC, TN, UC, Unknown Medical Care, Surgical, Consultation, Diagnostic X-Ray, Diagnostic Lab, Radiation Therapy, Anesthesia, Surgical Assistance, Other Medical, Blood Charges, Used Durable Medical Equipment, Durable Medical Equipment Purchase, Ambulatory Service Center Facility, Renal Supplies in the Home, Alternate Method Dialysis, Chronic Renal Disease (CRD) Equipment, Pre-Admission Testing, Durable Medical Equipment Rental, Pneumonia Vaccine, Second Surgical Opinion, Third Surgical Opinion, Social Work, Diagnostic Dental, Periodontics, Restorative, Endodontics, Maxillofacial Prosthetics, Adjunctive Dental Services, Health Benefit Plan Coverage, Plan Waiting Period, Chiropractic, Chiropractic Office Visits, Dental Care, Dental Crowns, Dental Accident, Orthodontics, Prosthodontics, Oral Surgery, Routine (Preventive) Dental, Home Health Care, Home Health Prescriptions, Home Health Visits, Hospice, Respite Care, Hospital, Hospital - Inpatient, Hospital - Room and Board, Hospital - Outpatient, Hospital - Emergency Accident, Hospital - Emergency Medical, Hospital - Ambulatory Surgical, Long Term Care, Major Medical, Medically Related Transportation, Air Transportation, Cabulance, Licensed Ambulance, General Benefits, In-vitro Fertilization, MRI/CAT Scan, Donor Procedures, Acupuncture, Newborn Care, Pathology, Smoking Cessation, Well Baby Care, Maternity, Transplants, Audiology Exam, Inhalation Therapy, Diagnostic Medical, Private Duty Nursing, Prosthetic Device, Dialysis, Otological Exam, Chemotherapy, Allergy Testing, Immunizations, Routine Physical, Family Planning, Infertility, Abortion, AIDS, Emergency Services, Cancer, Pharmacy, Free Standing Prescription Drug, Mail Order Prescription Drug, Brand Name Prescription Drug, Generic Prescription Drug, Podiatry, Podiatry - Office Visits, Podiatry - Nursing Home Visits, Professional (Physician), Anesthesiologist, Professional (Physician) Visit - Office, Professional (Physician) Visit - Inpatient, Professional (Physician) Visit - Outpatient, Professional (Physician) Visit - Nursing Home, Professional (Physician) Visit - Skilled Nursing Facility, Professional (Physician) Visit - Home, Psychiatric, Psychiatric - Room and Board, Psychotherapy, Psychiatric - Inpatient, Psychiatric - Outpatient, Rehabilitation, Rehabilitation - Room and Board, Rehabilitation - Inpatient, Rehabilitation - Outpatient, Occupational Therapy, Physical Medicine, Speech Therapy, Skilled Nursing Care, Skilled Nursing Care - Room and Board, Substance Abuse, Alcoholism, Drug Addiction, Vision (Optometry), Frames, Routine Exam, Lenses, Nonmedically Necessary Physical, Experimental Drug Therapy, Burn Care, Brand Name Prescription Drug - Formulary, Brand Name Prescription Drug - Non-Formulary, Independent Medical Evaluation, Partial Hospitalization (Psychiatric), Day Care (Psychiatric), Cognitive Therapy, Massage Therapy, Pulmonary Rehabilitation, Cardiac Rehabilitation, Pediatric, Nursery, Skin, Orthopedic, Cardiac, Lymphatic, Gastrointestinal, Endocrine, Neurology, Eye, Invasive Procedures, Gynecological, Obstetrical, Obstetrical/Gynecological, Mail Order Prescription Drug - Formulary, Mail Order Prescription Drug - Non-Formulary, Physician Visit - Office: Sick, Physician Visit - Office: Well, Coronary Care, Private Duty Nursing - Inpatient, Private Duty Nursing - Home, Surgical Benefits - Professional (Physician), Surgical Benefits - Facility, Mental Health Provider- Inpatient, Mental Health Provider - Outpatient, Mental Health Facility - Inpatient, Mental Health Facility - Outpatient, Substance Abuse Facility - Inpatient, Substance Abuse Facility - Outpatient, Screening X-ray, Screening laboratory, Mammogram, High Risk Patient, Mammogram, Low Risk Patient, Flu Vaccination, Eyewear and Eyewear Accessories, Case Management, Dermatology, Durable Medical Equipment, Diabetic Supplies, Generic Prescription Drug - Formulary, Generic Prescription Drug - Non-Formulary, Allergy, Intensive Care, Mental Health, Neonatol Intensive Care, Oncology, Physical Therapy, Pulmonary, Renal, Residential Psychiatric Treatment, Transitional Care, Transitional Nursery Care, Urgent Care, Unknown Code identifying the type of insurance policy.
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU, Unknown The full name of the insurance type code.
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan, Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan, Medicare Secondary, No-fault Insurance including Auto is Primary, Medicare Secondary Worker's Compensation, Medicare Secondary Public Health Service (PHS)or Other Federal Agency, Medicare Secondary Black Lung, Medicare Secondary Veteran's Administration, Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP), Medicare Secondary, Other Liability Insurance is Primary, Auto Insurance Policy, Commercial, Consolidated Omnibus Budget Reconciliation Act (COBRA), Medicare Conditionally Primary, Disability, Disability Benefits, Exclusive Provider Organization, Family or Friends, Group Policy, Health Maintenance Organization (HMO), Health Maintenance Organization (HMO) - Medicare Risk, Special Low Income Medicare Beneficiary, Indemnity, Individual Policy, Long Term Care, Long Term Policy, Life Insurance, Litigation, Medicare Part A, Medicare Part B, Medicaid, Medigap Part A, Medigap Part B, Medicare Primary, Other, Property Insurance - Personal, Personal, Personal Payment (Cash - No Insurance), Preferred Provider Organization (PPO), Point of Service (POS), Qualified Medicare Beneficiary, Property Insurance - Real, Supplemental Policy, Tax Equity Fiscal Responsibility Act (TEFRA), Workers Compensation, Wrap Up Policy, Unknown The specific product name or special program name for an insurance plan. For example Gold 1-2-3.
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.
Code indicating the time period for the benefit information.
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, Unknown The name of the time period qualifier code.
Note that for the patient's deductible, Calendar Year indicates the patient's total deductible amount for the year, while Remaining indicates the amount left to meet the deductible. Visit Payer benefit response to learn more about deductibles.
Hour, Day, 24 Hours, Years, Service Year, Calendar Year, Year to Date, Contract, Episode, Visit, Outlier, Remaining, Exceeded, Not Exceeded, Lifetime, Lifetime Remaining, Month, Week, Admission, Unknown The monetary benefit amount, such as a patient's co-pay or deductible. This value is expressed as a decimal, such as 100.00.
The payer will always send a value in this property when the benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down. For those codes, this value represents the patient's portion of responsibility.
The payer will never send this value when benefitsInformation.code = A - Co-Insurance. This property can contain zero when the patient has no responsibility.
Learn more about patient costs.
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.
Code indicating the type of quantity for the benefit.
8H, 99, CA, CE, D3, DB, DY, HS, LA, LE, M2, MN, P6, QA, S7, S8, VS, YY, Unknown The name of the quantity qualifier code.
Minimum, Quantity Used, Covered - Actual, Covered - Estimated, Number of Co-insurance Days, Deductible Blood Units, Days, Hours, Life-time Reserve - Actual, Life-time Reserve - Estimated, Maximum, Month, Number of Services or Procedures, Quantity Approved, Age, High Value, Age, Low Value, Visits, Years, Unknown The quantity of the benefit, qualified by the type specified in quantityQualifier. For example, 10 when the quantityQualifier is Visits.
Code indicating whether the benefit is subject to prior authorization or certification.
N, U, Y Code indicating whether the benefit is in-network or out-of-network. Can be Y - Yes, N - No, U - Unknown, or W - Not Applicable
Code U indicates that it is unknown whether the benefits are in or out-of-network. Code W indicates that the benefit applies to both in and out-of-network providers.
Note that this property 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.
Y, N, U, W The name of the in-plan network indicator code.
Yes, No, Unknown, Not Applicable The loop header identifier number in the LS segment of the original X12 EDI transaction.
The loop trailer identifier number in the LE segment of the original X12 EDI transaction.
Identifies relevant medical procedures by their standard codes and modifiers (if applicable).
Identifies the external code list used to provide the specified procedure or service codes. Can be AD - American Dental Association, CJ - Current Procedural Terminology (CPT) codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ID - International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, N4 - National Drug Code in 5-4-2 Format, or ZZ - Mutually Defined
The name of the productOrServiceIdQualifierCode. For example, American Dental Association.
The procedure code. Many payers do not support eligibility checks for specific procedure codes. If the payer does not support procedure codes, they return a generic benefits response for the service type code 30.
Procedure modifiers that provides additional information related to the performance of the service.
The product or service ID. This value represents the end of the range of applicable procedure codes. The beginning of the range is listed in procedureCode.
The diagnosis code pointer.
Identifying information specific to this type of benefit.
The insurance plan number.
The patient's policy number.
The patient's member ID.
The family unit number. This is returned when the payer is a pharmacy benefits manager (PBM) and the patient has a suffix to their member ID number that is used in the NCPDP Telecom Standard Insurance Segment, in field 303-C3 (Person Code). For all other uses, the family unit number (suffix) is considered part of the patient's member ID number.
The group number for the patient's health insurance plan.
Group name
Plan name
Plan network name
The referral number.
The alternative list ID. This identifier allows the payer to specify a list of drugs and its alternative drugs with the associated formulary status for the patient.
The coverage list ID. This identifier allows the payer to specify the identifier of a list of drugs that have coverage limitations for the associated patient.
The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.
The drug formulary number.
The prior authorization number.
The insurance policy number.
The medical assistance category.
The plan network identification number.
The Medicaid Recipient Identification number.
The delivery or usage pattern for the benefits.
Code specifying the type of quantity.
DY, FL, HS, MN, VS, Unknown The name of the quantityQualifierCode. For example, Days.
Days, Units, Hours, Month, Visits, Unknown The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.
This shape is deprecated.
Days, Months, Visits, Week, Years, Unknown Code specifying the unit of measurement for the quantity.
DA, MO, VS, WK, YR, Unknown The name of the unitForMeasurementQualifierCode. For example, Days.
Days, Months, Visits, Week, Years, Unknown Specifies the sampling frequency, based on the unit of measure. For example every 2 months or once per calendar year.
Code specifying the time period for the benefit information.
6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, Unknown The name of the timePeriodQualifierCode. For example, Calendar Year.
Hour, Day, Years, Service Year, Calendar Year, Year to Date, Contract, Episode, Visit, Outlier, Remaining, Exceeded, Not Exceeded, Lifetime, Lifetime Remaining, Month, Week, Unknown The number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.
The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
1st Week of the Month, 2nd Week of the Month, 3rd Week of the Month, 4th Week of the Month, 5th Week of the Month, 1st & 3rd Week of the Month, 2nd & 4th Week of the Month, 1st Working Day of Period, Last Working Day of Period, Monday through Friday, Monday through Saturday, Monday through Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Monday through Thursday, Immediately, As Directed, Daily Mon. Through Fri., 1/2 Mon. & 1/2 Tues., 1/2 Tues. & 1/2 Thurs., 1/2 Wed. & 1/2 Fri., Once Anytime Mon. through Fri., Tuesday through Friday, Monday, Tuesday and Thursday, Monday, Tuesday and Friday, Wednesday and Thursday, Monday, Wednesday and Thursday, Tuesday, Thursday and Friday, 1/2 Tues. & 1/2 Fri., 1/2 Mon. & 1/2 Wed., 1/3 Mon., 1/3 Wed., 1/3 Fri., Whenever Necessary, 1/2 By Wed. Bal. By Fri., None (Also Used to Cancel or Override a Previous Pattern), Unknown Code that specifies the routine shipments, deliveries, or calendar pattern. For example 9 - Last Working Day of Period. Visit Eligibility code lists for a complete list.
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, H, J, K, L, M, N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y, Unknown The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
1st Week of the Month, 2nd Week of the Month, 3rd Week of the Month, 4th Week of the Month, 5th Week of the Month, 1st & 3rd Week of the Month, 2nd & 4th Week of the Month, 1st Working Day of Period, Last Working Day of Period, Monday through Friday, Monday through Saturday, Monday through Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Monday through Thursday, Immediately, As Directed, Daily Mon. Through Fri., 1/2 Mon. & 1/2 Tues., 1/2 Tues. & 1/2 Thurs., 1/2 Wed. & 1/2 Fri., Once Anytime Mon. through Fri., Tuesday through Friday, Monday, Tuesday and Thursday, Monday, Tuesday and Friday, Wednesday and Thursday, Monday, Wednesday and Thursday, Tuesday, Thursday and Friday, 1/2 Tues. & 1/2 Fri., 1/2 Mon. & 1/2 Wed., 1/3 Mon., 1/3 Wed., 1/3 Fri., Whenever Necessary, 1/2 By Wed. Bal. By Fri., None (Also Used to Cancel or Override a Previous Pattern), Unknown The name of the deliveryPatternTimeCode.
1st Shift (Normal Working Hours), 2nd Shift, 3rd Shift, A.M., P.M., As Directed, Any Shift, None (Also Used to Cancel or Override a Previous Pattern), Unknown A code specifying the time for routine shipments or deliveries.
A, B, C, D, E, F, G, Y, Unknown The name of the deliveryPatternTimeCode.
1st Shift (Normal Working Hours), 2nd Shift, 3rd Shift, A.M., P.M., As Directed, Any Shift, None (Also Used to Cancel or Override a Previous Pattern), Unknown A free-form message containing additional information about the benefits in the response.
A free-form message containing additional information about the benefits in the response.
Used when there are multiple Nature of Injury Codes or a Facility Type Codes included in the response.
Identifies a specific industry code list. Can be GR - National Council on Compensation Insurance (NCCI) Nature of Injury Code, NI - Nature of Injury Code, or ZZ - Mutually Defined.
When this is set to ZZ, the industryCode property will be set to a place of service code.
The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
The specific industry code. When codeListQualifierCode is set to ZZ - Mutually Defined, this property will be set to a place of service code. Visit the Place of Service Code Set for a complete list of these codes and their descriptions.
The name of the industryCode. For example Pharmacy when the code is 01.
The code category. Always set to 44 - Nature of Injury.
Description of injured body parts.
All other entities associated with the eligibility or benefits.
Identify another entity associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer.
Code identifying an organizational entity, a physical location, property or an individual.
Contracted Service Provider, Preferred Provider Organization (PPO), Provider, Third-Party Administrator, Employer, Other Physician, Facility, Gateway Provider, Group, Independent Physicians Association (IPA), Insured or Subscriber, Legal Representative, Origin Carrier, Primary Care Provider, Prior Insurance Carrier, Plan Sponsor, Payer, Primary Payer, Secondary Payer, Tertiary Payer, Party Performing Verification, Vendor, Organization Completing Configuration Change, Utilization Management Organization, Managed Care Organization, Unknown The type of entity.
Person, Non-Person Entity The last name (if the entity is a person) or the business name (if the entity is an organization).
The first name of the entity, if the entity is a person.
The middle name or initial of the entity, if the entity is a person.
The name suffix, such as Sr. Jr. or III.
Code identifying the type of value provided in entityIdentificationValue. For example, FI - Federal Taxpayer's Identification Number.
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX, Unknown The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient.
01, 02, 27, 41, 48, 65, 72 The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3The provider code.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The provider's taxonomy code.
Information indicating how likely it is that this coverage is a match for the patient submitted in the insurance discovery request.
Even if the confidence level is high, you must always check the subscriber information to confirm that the coverage is a match for the patient.
The number of potential coverage matches for the patient. This will be 0 if Stedi didn't find any matching coverage.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Learn more
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
04, 15, 33, 35, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 97, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Resubmission allowed, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly Was this page helpful?
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1 \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"provider": {
"npi": "1999999984"
},
"subscriber": {
"firstName": "John",
"lastName": "Smith",
"middleName": "Robert",
"dateOfBirth": "19800101",
"ssn": "123456789",
"gender": "M",
"address": {
"address1": "123 Main St",
"city": "Springfield",
"state": "IL",
"postalCode": "62701"
}
},
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
}
}'{
"discoveryId": "12345678-abcd-4321-efgh-987654321abc",
"items": [
{
"provider": {
"providerName": "provider",
"entityType": "Non-Person Entity",
"npi": "1999999984"
},
"subscriber": {
"memberId": "987654321000",
"firstName": "John",
"lastName": "Doe",
"middleName": "Smith",
"gender": "M",
"dateOfBirth": "19900115",
"groupNumber": "123456-78",
"planNumber": "123456-EXMPL9876",
"groupDescription": "Individual On-Exchange",
"address": {
"address1": "123 Main Street",
"city": "ANYTOWN",
"state": "CA",
"postalCode": "12345"
}
},
"payer": {
"name": "EXAMPLE INSURANCE CO"
},
"planInformation": {
"planNumber": "123456-EXMPL9876",
"groupNumber": "123456-78",
"groupDescription": "Individual On-Exchange"
},
"planDateInformation": {
"planBegin": "20250101",
"eligibilityBegin": "20250101",
"service": "20250301"
},
"benefitsInformation": [
{
"inPlanNetworkIndicatorCode": "W",
"benefitsRelatedEntities": [
{
"entityIdentifier": "Primary Care Provider",
"entityIdentification": "XX",
"entityName": "Dough",
"entityIdentificationValue": "1234567890",
"entityFirstname": "Jane",
"entityType": "Person"
}
],
"additionalInformation": [
{
"description": "To determine if a prior authorization is required, please check the health plan's website."
}
],
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"inPlanNetworkIndicator": "Not Applicable",
"name": "Active Coverage",
"code": "1",
"planCoverage": "Gold Plan"
},
{
"serviceTypes": [
"Medical Care"
],
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "W",
"serviceTypeCodes": [
"1"
],
"inPlanNetworkIndicator": "Not Applicable",
"code": "1"
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "Y",
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan"
},
{
"inPlanNetworkIndicator": "Yes",
"code": "A",
"serviceTypeCodes": [
"4"
],
"name": "Co-Insurance",
"coverageLevel": "Family",
"serviceTypes": [
"Diagnostic X-Ray"
],
"inPlanNetworkIndicatorCode": "Y",
"benefitPercent": "0.5",
"planCoverage": "Gold Plan",
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"coverageLevelCode": "FAM"
},
{
"name": "Non-Covered",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"code": "I"
},
{
"code": "1",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Diagnostic Lab"
],
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"serviceTypeCodes": [
"5"
]
},
{
"code": "B",
"name": "Co-Payment",
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"coverageLevelCode": "FAM",
"benefitAmount": "20",
"coverageLevel": "Family",
"serviceTypeCodes": [
"5"
],
"serviceTypes": [
"Diagnostic Lab"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "per visit"
}
]
},
{
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"5"
],
"name": "Non-Covered",
"code": "I",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Diagnostic Lab"
]
},
{
"serviceTypeCodes": [
"12"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1"
},
{
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"code": "A",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"serviceTypeCodes": [
"12"
]
},
{
"name": "Non-Covered",
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"12"
]
},
{
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"code": "1",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"serviceTypeCodes": [
"13"
]
},
{
"coverageLevel": "Family",
"inPlanNetworkIndicator": "Yes",
"benefitPercent": "0.5",
"timeQualifier": "Visit",
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"code": "A",
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"13"
],
"timeQualifierCode": "27",
"name": "Co-Insurance",
"inPlanNetworkIndicatorCode": "Y"
},
{
"inPlanNetworkIndicator": "No",
"code": "I",
"name": "Non-Covered",
"serviceTypeCodes": [
"13"
],
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N"
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"18"
],
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"code": "1",
"planCoverage": "Gold Plan",
"serviceTypes": [
"Durable Medical Equipment Rental"
]
},
{
"serviceTypes": [
"Durable Medical Equipment Rental"
],
"serviceTypeCodes": [
"18"
],
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"coverageLevel": "Family",
"inPlanNetworkIndicatorCode": "Y",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"benefitPercent": "0.5",
"timeQualifierCode": "27",
"coverageLevelCode": "FAM"
},
{
"serviceTypeCodes": [
"18"
],
"serviceTypes": [
"Durable Medical Equipment Rental"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"code": "I",
"name": "Non-Covered"
},
{
"serviceTypeCodes": [
"33"
],
"serviceTypes": [
"Chiropractic"
],
"planCoverage": "Gold Plan",
"additionalInformation": [
{
"description": "Limited to 26 visits per year (visits in excess of 26 require prior authorization)."
}
],
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"code": "1"
},
{
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"timeQualifierCode": "27",
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"code": "A",
"name": "Co-Insurance",
"serviceTypes": [
"Chiropractic"
],
"serviceTypeCodes": [
"33"
],
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevelCode": "FAM"
},
{
"planCoverage": "Gold Plan",
"serviceTypes": [
"Chiropractic"
],
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"code": "I",
"serviceTypeCodes": [
"33"
]
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"48"
],
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"serviceTypes": [
"Hospital - Inpatient"
],
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan"
},
{
"code": "A",
"coverageLevel": "Family",
"benefitPercent": "0.5",
"timeQualifierCode": "27",
"name": "Co-Insurance",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypes": [
"Hospital - Inpatient"
],
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"48"
]
},
{
"serviceTypeCodes": [
"48"
],
"serviceTypes": [
"Hospital - Inpatient"
],
"code": "I",
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No"
},
{
"serviceTypes": [
"Hospital - Outpatient"
],
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"serviceTypeCodes": [
"50"
]
},
{
"timeQualifier": "Visit",
"coverageLevelCode": "FAM",
"code": "A",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"serviceTypeCodes": [
"50"
],
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"benefitPercent": "0.5",
"serviceTypes": [
"Hospital - Outpatient"
],
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27"
},
{
"serviceTypeCodes": [
"50"
],
"serviceTypes": [
"Hospital - Outpatient"
],
"planCoverage": "Gold Plan",
"code": "I",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered"
},
{
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"51"
],
"serviceTypes": [
"Hospital - Emergency Accident"
],
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"name": "Active Coverage"
},
{
"timeQualifierCode": "27",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"serviceTypeCodes": [
"51"
],
"timeQualifier": "Visit",
"serviceTypes": [
"Hospital - Emergency Accident"
],
"benefitPercent": "0.5",
"code": "A",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM"
},
{
"planCoverage": "Gold Plan",
"serviceTypes": [
"Hospital - Emergency Accident"
],
"code": "1",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"51"
]
},
{
"coverageLevel": "Family",
"code": "A",
"benefitPercent": "0.5",
"serviceTypeCodes": [
"51"
],
"planCoverage": "Gold Plan",
"timeQualifierCode": "27",
"name": "Co-Insurance",
"serviceTypes": [
"Hospital - Emergency Accident"
],
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "N"
},
{
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"code": "1",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"serviceTypes": [
"Hospital - Emergency Medical"
],
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"52"
],
"inPlanNetworkIndicator": "Yes"
},
{
"inPlanNetworkIndicatorCode": "Y",
"timeQualifier": "Visit",
"benefitPercent": "0.5",
"serviceTypes": [
"Hospital - Emergency Medical"
],
"code": "A",
"serviceTypeCodes": [
"52"
],
"coverageLevelCode": "FAM",
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"timeQualifierCode": "27",
"coverageLevel": "Family",
"inPlanNetworkIndicator": "Yes"
},
{
"serviceTypes": [
"Hospital - Emergency Medical"
],
"serviceTypeCodes": [
"52"
],
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "N",
"code": "1"
},
{
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"serviceTypeCodes": [
"52"
],
"serviceTypes": [
"Hospital - Emergency Medical"
],
"code": "A",
"planCoverage": "Gold Plan",
"benefitPercent": "0.5"
},
{
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"code": "1",
"serviceTypes": [
"Hospital - Ambulatory Surgical"
]
},
{
"timeQualifier": "Visit",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"coverageLevelCode": "FAM",
"benefitPercent": "0.5",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"serviceTypes": [
"Hospital - Ambulatory Surgical"
],
"code": "A",
"name": "Co-Insurance"
},
{
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"serviceTypeCodes": [
"53"
],
"code": "I",
"serviceTypes": [
"Hospital - Ambulatory Surgical"
]
},
{
"serviceTypeCodes": [
"62"
],
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"MRI/CAT Scan"
],
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1"
},
{
"timeQualifierCode": "27",
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"planCoverage": "Gold Plan",
"serviceTypes": [
"MRI/CAT Scan"
],
"serviceTypeCodes": [
"62"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"timeQualifier": "Visit"
},
{
"serviceTypes": [
"MRI/CAT Scan"
],
"serviceTypeCodes": [
"62"
],
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered"
},
{
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"code": "1",
"serviceTypeCodes": [
"65"
],
"serviceTypes": [
"Newborn Care"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
]
},
{
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"benefitPercent": "0.5",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevelCode": "FAM",
"serviceTypes": [
"Newborn Care"
],
"coverageLevel": "Family",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"name": "Co-Insurance"
},
{
"name": "Non-Covered",
"code": "I",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"serviceTypes": [
"Newborn Care"
]
},
{
"planCoverage": "Gold Plan",
"code": "1",
"serviceTypes": [
"Well Baby Care"
],
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Covered in accordance with ACA guidelines."
}
],
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"68"
]
},
{
"code": "B",
"serviceTypes": [
"Well Baby Care"
],
"benefitAmount": "0",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"68"
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"name": "Co-Payment"
},
{
"serviceTypeCodes": [
"68"
],
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"code": "I",
"serviceTypes": [
"Well Baby Care"
],
"planCoverage": "Gold Plan"
},
{
"serviceTypeCodes": [
"69"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"code": "1",
"serviceTypes": [
"Maternity"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes"
},
{
"serviceTypeCodes": [
"69"
],
"benefitPercent": "0.5",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"serviceTypes": [
"Maternity"
],
"timeQualifier": "Visit",
"coverageLevel": "Family",
"name": "Co-Insurance",
"timeQualifierCode": "27"
},
{
"serviceTypeCodes": [
"69"
],
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"serviceTypes": [
"Maternity"
]
},
{
"code": "1",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"86"
],
"name": "Active Coverage",
"serviceTypes": [
"Emergency Services"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"86"
],
"coverageLevel": "Family",
"timeQualifierCode": "27",
"serviceTypes": [
"Emergency Services"
],
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"timeQualifier": "Visit"
},
{
"inPlanNetworkIndicator": "No",
"code": "1",
"name": "Active Coverage",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"86"
],
"inPlanNetworkIndicatorCode": "N",
"serviceTypes": [
"Emergency Services"
]
},
{
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"code": "A",
"serviceTypeCodes": [
"86"
],
"serviceTypes": [
"Emergency Services"
],
"timeQualifier": "Visit",
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "N",
"timeQualifierCode": "27",
"inPlanNetworkIndicator": "No",
"name": "Co-Insurance",
"planCoverage": "Gold Plan"
},
{
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"serviceTypes": [
"Pharmacy"
],
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"88"
],
"code": "1",
"planCoverage": "Gold Plan"
},
{
"serviceTypeCodes": [
"88"
],
"coverageLevel": "Family",
"name": "Co-Payment",
"serviceTypes": [
"Pharmacy"
],
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"timeQualifierCode": "27",
"code": "B",
"benefitAmount": "10",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"coverageLevelCode": "FAM",
"additionalInformation": [
{
"description": "per prescription"
}
]
},
{
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"serviceTypeCodes": [
"88"
],
"inPlanNetworkIndicator": "No",
"code": "I",
"serviceTypes": [
"Pharmacy"
],
"planCoverage": "Gold Plan"
},
{
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"code": "1",
"serviceTypeCodes": [
"98"
],
"additionalInformation": [
{
"description": "PCP"
}
],
"name": "Active Coverage"
},
{
"additionalInformation": [
{
"description": "per visit"
},
{
"description": "PCP"
}
],
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevelCode": "FAM",
"timeQualifierCode": "27",
"serviceTypeCodes": [
"98"
],
"benefitAmount": "15",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"timeQualifier": "Visit",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"code": "B"
},
{
"code": "I",
"serviceTypeCodes": [
"98"
],
"planCoverage": "Gold Plan",
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "PCP"
}
]
},
{
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"additionalInformation": [
{
"description": "Specialist"
},
{
"description": "Covered No Limit."
}
],
"code": "1",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"98"
]
},
{
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "per visit"
},
{
"description": "Specialist"
}
],
"benefitAmount": "30",
"coverageLevel": "Family",
"code": "B",
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"timeQualifierCode": "27",
"coverageLevelCode": "FAM",
"name": "Co-Payment",
"serviceTypeCodes": [
"98"
]
},
{
"additionalInformation": [
{
"description": "Specialist"
}
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"98"
],
"planCoverage": "Gold Plan",
"code": "I",
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N"
},
{
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"A4"
],
"planCoverage": "Gold Plan",
"code": "1",
"serviceTypes": [
"Psychiatric"
],
"inPlanNetworkIndicatorCode": "Y",
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit. (Primary Care Provider (PCP) and other practitioner office visits do not require prior authorization.) Note| Services (excluding Emergency Room Care / Emergency Services) rendered by an out-of-network provider"
}
]
},
{
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"serviceTypes": [
"Psychiatric"
],
"timeQualifierCode": "27",
"name": "Co-Insurance",
"serviceTypeCodes": [
"A4"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"code": "A"
},
{
"serviceTypeCodes": [
"A4"
],
"name": "Non-Covered",
"serviceTypes": [
"Psychiatric"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"inPlanNetworkIndicator": "No"
},
{
"name": "Active Coverage",
"code": "1",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
],
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes"
},
{
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"benefitPercent": "0.5",
"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
"name": "Co-Insurance",
"coverageLevelCode": "FAM",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
],
"inPlanNetworkIndicator": "Yes",
"coverageLevel": "Family",
"code": "A"
},
{
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"code": "I",
"planCoverage": "Gold Plan",
"name": "Non-Covered",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
]
},
{
"planCoverage": "Gold Plan",
"code": "1",
"serviceTypes": [
"Psychiatric - Inpatient"
],
"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"A7"
],
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage"
},
{
"timeQualifier": "Visit",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A7"
],
"timeQualifierCode": "27",
"name": "Co-Insurance",
"code": "A",
"serviceTypes": [
"Psychiatric - Inpatient"
],
"benefitPercent": "0.5"
},
{
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "No",
"serviceTypeCodes": [
"A7"
],
"serviceTypes": [
"Psychiatric - Inpatient"
],
"name": "Non-Covered",
"inPlanNetworkIndicatorCode": "N"
},
{
"code": "1",
"serviceTypes": [
"Psychiatric - Outpatient"
],
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A8"
],
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y"
},
{
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"serviceTypeCodes": [
"A8"
],
"benefitPercent": "0.5",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"code": "A",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Psychiatric - Outpatient"
]
},
{
"serviceTypes": [
"Psychiatric - Outpatient"
],
"inPlanNetworkIndicator": "No",
"name": "Non-Covered",
"serviceTypeCodes": [
"A8"
],
"code": "I",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N"
},
{
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"code": "1"
},
{
"inPlanNetworkIndicator": "Yes",
"serviceTypeCodes": [
"AD"
],
"planCoverage": "Gold Plan",
"coverageLevel": "Family",
"timeQualifierCode": "27",
"serviceTypes": [
"Occupational Therapy"
],
"code": "A",
"timeQualifier": "Visit",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicatorCode": "Y",
"benefitPercent": "0.5",
"name": "Co-Insurance"
},
{
"code": "I",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
],
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
"Speech Therapy"
],
"serviceTypeCodes": [
"AF"
],
"planCoverage": "Gold Plan",
"name": "Active Coverage",
"inPlanNetworkIndicatorCode": "Y"
},
{
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"coverageLevel": "Family",
"serviceTypeCodes": [
"AF"
],
"coverageLevelCode": "FAM",
"serviceTypes": [
"Speech Therapy"
],
"code": "A",
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
"timeQualifier": "Visit",
"inPlanNetworkIndicatorCode": "Y"
},
{
"planCoverage": "Gold Plan",
"name": "Non-Covered",
"code": "I",
"serviceTypeCodes": [
"AF"
],
"serviceTypes": [
"Speech Therapy"
],
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"serviceTypeCodes": [
"AG"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Limited to 150 days per year."
}
],
"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"code": "1",
"name": "Active Coverage",
"serviceTypes": [
"Skilled Nursing Care"
],
"inPlanNetworkIndicatorCode": "Y"
},
{
"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
],
"planCoverage": "Gold Plan",
"name": "Co-Insurance",
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"code": "A",
"coverageLevel": "Family",
"benefitPercent": "0.5",
"inPlanNetworkIndicator": "Yes",
"timeQualifierCode": "27",
"inPlanNetworkIndicatorCode": "Y",
"timeQualifier": "Visit"
},
{
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"AG"
],
"serviceTypes": [
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],
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"name": "Non-Covered",
"code": "I"
},
{
"name": "Active Coverage",
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"inPlanNetworkIndicator": "Yes",
"serviceTypes": [
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],
"serviceTypeCodes": [
"BZ"
],
"planCoverage": "Gold Plan",
"additionalInformation": [
{
"description": "Covered in accordance with ACA guidelines."
}
],
"code": "1"
},
{
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"inPlanNetworkIndicatorCode": "Y",
"serviceTypeCodes": [
"BZ"
],
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"name": "Co-Payment",
"coverageLevel": "Family",
"timeQualifierCode": "27",
"code": "B",
"serviceTypes": [
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],
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"benefitAmount": "0"
},
{
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],
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"serviceTypeCodes": [
"BZ"
],
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"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"inPlanNetworkIndicator": "No"
},
{
"code": "1",
"inPlanNetworkIndicatorCode": "Y",
"planCoverage": "Gold Plan",
"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"serviceTypes": [
"Mental Health"
],
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"serviceTypeCodes": [
"MH"
]
},
{
"serviceTypeCodes": [
"MH"
],
"code": "A",
"serviceTypes": [
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],
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"planCoverage": "Gold Plan",
"timeQualifier": "Visit",
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"name": "Co-Insurance",
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"inPlanNetworkIndicatorCode": "Y",
"timeQualifierCode": "27"
},
{
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"planCoverage": "Gold Plan",
"serviceTypes": [
"Mental Health"
],
"name": "Non-Covered",
"code": "I",
"serviceTypeCodes": [
"MH"
],
"inPlanNetworkIndicatorCode": "N"
},
{
"code": "1",
"serviceTypes": [
"Physical Therapy"
],
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"inPlanNetworkIndicator": "Yes",
"name": "Active Coverage",
"serviceTypeCodes": [
"PT"
]
},
{
"additionalInformation": [
{
"description": "per visit"
}
],
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"coverageLevel": "Family",
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"coverageLevelCode": "FAM",
"benefitAmount": "15",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"code": "B",
"serviceTypeCodes": [
"PT"
],
"serviceTypes": [
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],
"timeQualifier": "Visit"
},
{
"serviceTypeCodes": [
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],
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],
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"code": "I",
"inPlanNetworkIndicatorCode": "N"
},
{
"serviceTypeCodes": [
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],
"serviceTypes": [
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],
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"planCoverage": "Gold Plan"
},
{
"serviceTypes": [
"Urgent Care"
],
"timeQualifierCode": "27",
"serviceTypeCodes": [
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],
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"benefitAmount": "10",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"coverageLevel": "Family",
"additionalInformation": [
{
"description": "per visit"
}
],
"code": "B",
"inPlanNetworkIndicator": "Yes"
},
{
"name": "Active Coverage",
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
],
"planCoverage": "Gold Plan",
"inPlanNetworkIndicatorCode": "N",
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"inPlanNetworkIndicator": "No",
"code": "1"
},
{
"benefitAmount": "10",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "per visit"
}
],
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],
"coverageLevelCode": "FAM",
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"serviceTypes": [
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],
"coverageLevel": "Family",
"timeQualifierCode": "27"
},
{
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"timeQualifierCode": "23",
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"code": "C",
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"inPlanNetworkIndicator": "Yes",
"planCoverage": "Gold Plan",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
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],
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"serviceTypes": [
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],
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"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"timeQualifier": "Remaining",
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"inPlanNetworkIndicatorCode": "Y"
},
{
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],
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},
{
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},
{
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},
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{
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},
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}
],
"confidence": {
"level": "REVIEW_NEEDED",
"reason": "This record was identified as a low confidence match due to a DOB partial match"
}
}
],
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"traceId": "1-abcdef12-123456789abcdef123456789"
},
"status": "COMPLETE"
}