Insurance Discovery Check

Submit an insurance discovery check in JSON format

POST /insurance-discovery/check/v1

Insurance discovery checks search for a patient's active coverage using only their demographic data.

1. Call this endpoint with as much patient demographic information as possible.
2. Stedi searches for active coverage for the patient.
3. The endpoint returns an array of potential active coverages along with subscriber details and benefits information.

We recommend using insurance discovery checks as a backup when eligibility checks fail or aren't possible. Because of their limitations, you shouldn't rely on them as your primary method for verifying patient coverage.

Authorizations

Authorization · Required Header

A Stedi API Key for authentication.

Body

application/json

dependent · Object

Demographic 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 subscriber object 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.

address · dependent.address · Object

The dependent's address. We strongly recommend providing this information if possible to improve the probability of finding matching coverage.

We especially recommend providing the patient’s ZIP code, as this helps narrow down the list of probable payers. Zip code search isn’t an exact match, so even the first 3-4 digits of the patient’s current zip code can help improve the results. If the patient’s current address isn’t available, you can try a full or partial zip code from one of the patient’s previous addresses or even one in close proximity.

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

The first line of the address.

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

The second line of the address.

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

The city.

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

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · dependent.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

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

The dependent's date of birth (DOB), formatted as YYYYMMDD.

firstName · dependent.firstName · String Required Length: 1 - 25

The dependent's first name.

gender · dependent.gender · String

The dependent's gender. This can be set to either M - Male or F - Female.

Possible values

M

F

lastName · dependent.lastName · String Required Length: 1 - 25

The dependent's last name.

middleName · dependent.middleName · String Length: 1 - 25

The dependent's middle name or initial.

ssn · dependent.ssn · String Regex pattern: ^(?:\d{9}|\d{3}-\d{2}-\d{4}|\d{4})$

The dependent's Social Security Number (SSN). We strongly recommend providing this information if possible to improve the probability of finding matching coverage.

encounter · Object

The 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.

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

The beginning date, formatted as YYYYMMDD.

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

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.

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

The end date, formatted as YYYYMMDD. If you don't specify an end date, Stedi defaults to the same date as beginningDateOfService.

provider · Object Required

Information about the provider requesting the insurance discovery check.

npi · provider.npi · String Required Regex pattern: ^[12].*$ Length: 10 - 15

The provider's National Provider Identifier (NPI).

subscriber · Object Required

Demographic 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.

address · subscriber.address · Object

The subscriber's current or previous address. We strongly recommend providing this information if possible to improve the probability of finding matching coverage.

We especially recommend providing the patient’s ZIP code, as this helps narrow down the list of probable payers. Zip code search isn’t an exact match, so even the first 3-4 digits of the patient’s current zip code can help improve the results. If the patient’s current address isn’t available, you can try a full or partial zip code from one of the patient’s previous addresses or even one in close proximity.

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

The first line of the address.

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

The second line of the address.

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

The city.

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

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · subscriber.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

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

The subscriber's date of birth (DOB), formatted as YYYYMMDD.

firstName · subscriber.firstName · String Required Length: 1 - 25

The subscriber's first name.

gender · subscriber.gender · String

The subscriber's gender. This can be set to either M - Male or F - Female.

Possible values

M

F

lastName · subscriber.lastName · String Required Length: 1 - 25

The subscriber's last name.

middleName · subscriber.middleName · String Length: 1 - 25

The subscriber's middle name or initial.

ssn · subscriber.ssn · String Regex pattern: ^(?:\d{9}|\d{3}-\d{2}-\d{4}|\d{4})$

The subscriber's Social Security Number (SSN). We strongly recommend providing this information if possible to improve the probability of finding matching coverage. The patient's full SSN is preferred, but even the last 4 digits of the SSN can help narrow down matching coverage.

Response

application/json

InsuranceDiscoveryCheck 200 response

coveragesFound · Integer

The number of potential coverage matches for the patient. This will be 0 if Stedi didn't find any matching coverage.

discoveryId · String

A unique ID for this insurance discovery check. You can use it to retrieve the results asynchronously through the Insurance Discovery Check Results endpoint.

errors · Array of Objects

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

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

code · errors[].code · String

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

Payers may sometimes return other non-compliant values.

Possible values

04

15

33

35

41

description · errors[].description · String

The error description.

field · errors[].field · String

The error type, AAA.

followupAction · errors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

location · errors[].location · String

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

possibleResolutions · errors[].possibleResolutions · String

Information to help you correct the error.

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

items · Array of Objects

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

benefitsInformation · items[].benefitsInformation · Array of Objects

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

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

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

additionalInformation · items[].benefitsInformation[].additionalInformation · Array of Objects

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

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

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

authOrCertIndicator · items[].benefitsInformation[].authOrCertIndicator · String

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

N

U

Y

benefitAmount · items[].benefitsInformation[].benefitAmount · String

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

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

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

Learn more about patient costs.

benefitPercent · items[].benefitsInformation[].benefitPercent · String

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

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

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

Learn more about patient costs.

benefitQuantity · items[].benefitsInformation[].benefitQuantity · String

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

benefitsAdditionalInformation · items[].benefitsInformation[].benefitsAdditionalInformation · Object

Identifying information specific to this type of benefit.

alternativeListId · items[].benefitsInformation[].benefitsAdditionalInformation.alternativeListId · String

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

coverageListId · items[].benefitsInformation[].benefitsAdditionalInformation.coverageListId · String

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

drugFormularyNumber · items[].benefitsInformation[].benefitsAdditionalInformation.drugFormularyNumber · String

The drug formulary number.

familyUnitNumber · items[].benefitsInformation[].benefitsAdditionalInformation.familyUnitNumber · String

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

groupDescription · items[].benefitsInformation[].benefitsAdditionalInformation.groupDescription · String

Group name

groupNumber · items[].benefitsInformation[].benefitsAdditionalInformation.groupNumber · String

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

hicNumber · items[].benefitsInformation[].benefitsAdditionalInformation.hicNumber · String

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

insurancePolicyNumber · items[].benefitsInformation[].benefitsAdditionalInformation.insurancePolicyNumber · String

The insurance policy number.

medicaidRecepientIdNumber · items[].benefitsInformation[].benefitsAdditionalInformation.medicaidRecepientIdNumber · String

The Medicaid Recipient Identification number.

medicalAssistanceCategory · items[].benefitsInformation[].benefitsAdditionalInformation.medicalAssistanceCategory · String

The medical assistance category.

memberId · items[].benefitsInformation[].benefitsAdditionalInformation.memberId · String

The patient's member ID.

planDescription · items[].benefitsInformation[].benefitsAdditionalInformation.planDescription · String

Plan name

planNetworkDescription · items[].benefitsInformation[].benefitsAdditionalInformation.planNetworkDescription · String

Plan network name

planNetworkIdNumber · items[].benefitsInformation[].benefitsAdditionalInformation.planNetworkIdNumber · String

The plan network identification number.

planNumber · items[].benefitsInformation[].benefitsAdditionalInformation.planNumber · String

The insurance plan number.

policyNumber · items[].benefitsInformation[].benefitsAdditionalInformation.policyNumber · String

The patient's policy number.

priorAuthorizationNumber · items[].benefitsInformation[].benefitsAdditionalInformation.priorAuthorizationNumber · String

The prior authorization number.

referralNumber · items[].benefitsInformation[].benefitsAdditionalInformation.referralNumber · String

The referral number.

benefitsRelatedEntities · items[].benefitsInformation[].benefitsRelatedEntities · Array of Objects

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

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

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

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

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

The first line of the address.

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

The second line of the address.

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

The city.

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

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

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

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

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

The contact information.

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

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

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

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

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

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

The name of the contact person.

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

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

24

34

46

FA

FI

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

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

Contracted Service Provider

Preferred Provider Organization (PPO)

Provider

Third-Party Administrator

Employer

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

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

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

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

01

02

27

41

48

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

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

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

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

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

The provider's taxonomy code.

benefitsServiceDelivery · items[].benefitsInformation[].benefitsServiceDelivery · Array of Objects

The delivery or usage pattern for the benefits.

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

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

Payers may sometimes return other non-compliant values.

Possible values

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

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

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

Payers may sometimes return other non-compliant values.

Possible values

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

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

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

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

The name of the deliveryPatternTimeCode.

Payers may sometimes return other non-compliant values.

Possible values

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

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

The name of the deliveryPatternTimeCode.

Payers may sometimes return other non-compliant values.

Possible values

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

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

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

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

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

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

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

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

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

The name of the quantityQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Units

Hours

Month

Visits

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

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

Payers may sometimes return other non-compliant values.

Possible values

DY

FL

HS

MN

VS

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

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

Hour

Day

Years

Service Year

Calendar Year

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

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

Payers may sometimes return other non-compliant values.

Possible values

6

7

21

22

23

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

The name of the unitForMeasurementQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Months

Visits

Week

Years

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

The name of the unitForMeasurementQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Months

Visits

Week

Years

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

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

Payers may sometimes return other non-compliant values.

Possible values

DA

MO

VS

WK

YR

code · items[].benefitsInformation[].code · String

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

compositeMedicalProcedureIdentifier · items[].benefitsInformation[].compositeMedicalProcedureIdentifier · Object

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

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

The diagnosis code pointer.

procedureCode · items[].benefitsInformation[].compositeMedicalProcedureIdentifier.procedureCode · String

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

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

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

productOrServiceID · items[].benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceID · String

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

productOrServiceIdQualifier · items[].benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceIdQualifier · String

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

productOrServiceIdQualifierCode · items[].benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceIdQualifierCode · String

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

coverageLevel · items[].benefitsInformation[].coverageLevel · String

The full name of the coverage level code.

Payers may sometimes return other non-compliant values.

Possible values

Children Only

Dependents Only

Employee and Children

Employee Only

Employee and Spouse

coverageLevelCode · items[].benefitsInformation[].coverageLevelCode · String

Code indicating the level of coverage for the patient.

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

Payers may sometimes return other non-compliant values.

Possible values

CHD

DEP

ECH

EMP

ESP

eligibilityAdditionalInformationList · items[].benefitsInformation[].eligibilityAdditionalInformationList · Array of Objects

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

44

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

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

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

GR

NI

ZZ

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

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

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

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

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

Description of injured body parts.

headerLoopIdentifierCode · items[].benefitsInformation[].headerLoopIdentifierCode · String

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

inPlanNetworkIndicator · items[].benefitsInformation[].inPlanNetworkIndicator · String

The name of the in-plan network indicator code.

Payers may sometimes return other non-compliant values.

Possible values

Yes

No

Unknown

Not Applicable

inPlanNetworkIndicatorCode · items[].benefitsInformation[].inPlanNetworkIndicatorCode · String

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

Y

N

U

W

insuranceType · items[].benefitsInformation[].insuranceType · String

The full name of the insurance type code.

Payers may sometimes return other non-compliant values.

Possible values

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

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

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

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

insuranceTypeCode · items[].benefitsInformation[].insuranceTypeCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

12

13

14

15

16

name · items[].benefitsInformation[].name · String

The full name of the benefits information code.

Payers may sometimes return other non-compliant values.

Possible values

Active Coverage

Active - Full Risk Capitation

Active - Services Capitated

Active - Services Capitated to Primary Care Physician

Active - Pending Investigation

planCoverage · items[].benefitsInformation[].planCoverage · String

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

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

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

quantityQualifier · items[].benefitsInformation[].quantityQualifier · String

The name of the quantityQualifierCode.

Payers may sometimes return other non-compliant values.

Possible values

Minimum

Quantity Used

Covered - Actual

Covered - Estimated

Number of Co-insurance Days

quantityQualifierCode · items[].benefitsInformation[].quantityQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

8H

99

CA

CE

D3

serviceTypeCodes · items[].benefitsInformation[].serviceTypeCodes · Array of Strings

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

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

serviceTypes · items[].benefitsInformation[].serviceTypes · Array of Strings

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

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

Payers may sometimes return other non-compliant values.

Possible values

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

timeQualifier · items[].benefitsInformation[].timeQualifier · String

The name of the timeQualifierCode.

Payers may sometimes return other non-compliant values.

Possible values

Hour

Day

24 Hours

Years

Service Year

timeQualifierCode · items[].benefitsInformation[].timeQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

6

7

13

21

22

trailerLoopIdentifierCode · items[].benefitsInformation[].trailerLoopIdentifierCode · String

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

confidence · items[].confidence · Object

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

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

level · items[].confidence.level · String

The confidence level for the match.

Possible values

REVIEW_NEEDED

HIGH

reason · items[].confidence.reason · String

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

dependent · items[].dependent · Object

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

address · items[].dependent.address · Object

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

The first line of the address.

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

The second line of the address.

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

The city.

countryCode · items[].dependent.address.countryCode · String Length: 2

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · items[].dependent.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

birthSequenceNumber · items[].dependent.birthSequenceNumber · String

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

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

The member's date of birth.

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

The military service date.

dateTimePeriodFormatQualifier · items[].dependent.dateTimePeriodFormatQualifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

D8

RD8

description · items[].dependent.description · String

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

employmentStatusCode · items[].dependent.employmentStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AE

AO

AS

AT

AU

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

The military service end date.

entityIdentifier · items[].dependent.entityIdentifier · String

The entity identifier for the dependent.

Possible values

Dependent

entityType · items[].dependent.entityType · String

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

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

firstName · items[].dependent.firstName · String

The member's first name.

gender · items[].dependent.gender · String

Code indicating the patient's gender.

Possible values

M

F

U

governmentServiceAffiliationCode · items[].dependent.governmentServiceAffiliationCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

groupDescription · items[].dependent.groupDescription · String

Group name

groupNumber · items[].dependent.groupNumber · String

The group number associated with the insurance policy.

healthCareDiagnosisCodes · items[].dependent.healthCareDiagnosisCodes · Array of Objects

Information about the patient's healthcare diagnosis.

diagnosisCode · items[].dependent.healthCareDiagnosisCodes[].diagnosisCode · String

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

diagnosisTypeCode · items[].dependent.healthCareDiagnosisCodes[].diagnosisTypeCode · String

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

informationStatusCode · items[].dependent.informationStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

C

L

O

P

insuredIndicator · items[].dependent.insuredIndicator · String

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

Possible values

N

lastName · items[].dependent.lastName · String

The member's last name.

maintenanceReasonCode · items[].dependent.maintenanceReasonCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

25

maintenanceTypeCode · items[].dependent.maintenanceTypeCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

001

memberId · items[].dependent.memberId · String Deprecated

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

middleName · items[].dependent.middleName · String

The member's middle name or initial.

militaryServiceRankCode · items[].dependent.militaryServiceRankCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A1

A2

A3

B1

B2

planDescription · items[].dependent.planDescription · String

Plan name

planNetworkDescription · items[].dependent.planNetworkDescription · String

Plan network name

planNetworkIdNumber · items[].dependent.planNetworkIdNumber · String

The network identification number associated with the insurance policy.

planNumber · items[].dependent.planNumber · String

The plan number associated with the insurance policy.

relationToSubscriber · items[].dependent.relationToSubscriber · String

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

Possible values

Spouse

Child

Employee

Unknown

Organ Donor

relationToSubscriberCode · items[].dependent.relationToSubscriberCode · String

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

Possible values

01

19

20

21

39

responseProvider · items[].dependent.responseProvider · Object

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

aaaErrors · items[].dependent.responseProvider.aaaErrors · Array of Objects

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

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

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

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

The error description.

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

The error type, AAA.

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

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

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

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

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

Information to help you correct the error.

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

address · items[].dependent.responseProvider.address · Object

The provider's contact information.

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

The first line of the address.

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

The second line of the address.

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

The city.

countryCode · items[].dependent.responseProvider.address.countryCode · String Length: 2

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · items[].dependent.responseProvider.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId · items[].dependent.responseProvider.employersId · String Deprecated

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

entityIdentifier · items[].dependent.responseProvider.entityIdentifier · String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

entityType · items[].dependent.responseProvider.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

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

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

middleName · items[].dependent.responseProvider.middleName · String

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

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

The provider's National Provider Identifier (NPI).

payorIdentification · items[].dependent.responseProvider.payorIdentification · String

The Payor Identification.

pharmacyProcessorNumber · items[].dependent.responseProvider.pharmacyProcessorNumber · String

The pharmacy processor number.

providerCode · items[].dependent.responseProvider.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName · items[].dependent.responseProvider.providerFirstName · String

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

providerName · items[].dependent.responseProvider.providerName · String

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

providerOrgName · items[].dependent.responseProvider.providerOrgName · String

The provider's organization name.

referenceIdentification · items[].dependent.responseProvider.referenceIdentification · String

The Health Care Provider Taxonomy Code.

serviceProviderNumber · items[].dependent.responseProvider.serviceProviderNumber · String

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

servicesPlanID · items[].dependent.responseProvider.servicesPlanID · String

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

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

The Social Security Number (SSN).

suffix · items[].dependent.responseProvider.suffix · String

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

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

The member's Social Security Number (SSN).

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

The military service start date.

suffix · items[].dependent.suffix · String

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

uniqueHealthIdentifier · items[].dependent.uniqueHealthIdentifier · String

The member's unique health identifier.

payer · items[].payer · Object

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

centersForMedicareAndMedicaidPlanId · items[].payer.centersForMedicareAndMedicaidPlanId · String

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

contactInformation · items[].payer.contactInformation · Object

The payer's contact information.

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

contacts · items[].payer.contactInformation.contacts · Array of Objects

The contact information.

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

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

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

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

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

name · items[].payer.contactInformation.name · String

The name of the contact person.

entityIdentifier · items[].payer.entityIdentifier · String

The entity identifier code for the payer.

Payers may sometimes return other non-compliant values.

Possible values

Third-Party Administrator

Employer

Gateway Provider

Plan Sponsor

Payer

entityType · items[].payer.entityType · String

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

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

etin · items[].payer.etin · String

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

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

The payer's federal taxpayer's identification number.

firstName · items[].payer.firstName · String

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

lastName · items[].payer.lastName · String

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

middleName · items[].payer.middleName · String

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

naic · items[].payer.naic · String

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

name · items[].payer.name · String

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

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

The payer's National Provider Identifier (NPI).

payorIdentification · items[].payer.payorIdentification · String

The payor identification.

suffix · items[].payer.suffix · String

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

planDateInformation · items[].planDateInformation · Object

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

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

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

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

The admission date or dates.

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

The certification date.

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

The date when COBRA coverage begins.

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

The date when COBRA coverage ends.

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

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

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

The date when the plan information was last updated.

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

The discharge date.

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

The effective date of change.

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

Plan eligibility dates.

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

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

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

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

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

The date when the patient is enrolled in the plan.

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

The issue date.

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

Plan effective dates.

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

The date coverage from the plan begins.

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

The date coverage from the plan ends.

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

The date when the policy becomes effective.

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

The date when the policy expires.

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

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

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

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

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

The service date or dates.

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

The status date.

planInformation · items[].planInformation · Object

Additional identification for the patient's health plan.

agencyClaimNumber · items[].planInformation.agencyClaimNumber · String

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

alternativeListId · items[].planInformation.alternativeListId · String

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

caseNumber · items[].planInformation.caseNumber · String

The case number

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

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

classOfContractCode · items[].planInformation.classOfContractCode · String

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

contractNumber · items[].planInformation.contractNumber · String

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

coverageListId · items[].planInformation.coverageListId · String

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

drugFormularyNumber · items[].planInformation.drugFormularyNumber · String

The drug formulary number

electronicDevicePin · items[].planInformation.electronicDevicePin · String

The electronic device pin number

eligibilityCategory · items[].planInformation.eligibilityCategory · String

The eligibility category

facilityIdNumber · items[].planInformation.facilityIdNumber · String

The facility ID number

facilityNetworkIdentificationNumber · items[].planInformation.facilityNetworkIdentificationNumber · String

The facility network identification number

familyUnitNumber · items[].planInformation.familyUnitNumber · String

The family unit number

federalTaxpayersIdentificationNumber · items[].planInformation.federalTaxpayersIdentificationNumber · String

The federal taxpayer's identification number

groupDescription · items[].planInformation.groupDescription · String

The group description

groupNumber · items[].planInformation.groupNumber · String

The group number

hicNumber · items[].planInformation.hicNumber · String

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

idCardNumber · items[].planInformation.idCardNumber · String

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

idCardSerialNumber · items[].planInformation.idCardSerialNumber · String

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

insurancePolicyNumber · items[].planInformation.insurancePolicyNumber · String

The insurance policy number

issueNumber · items[].planInformation.issueNumber · String

The issue number

medicaidProviderNumber · items[].planInformation.medicaidProviderNumber · String

The Medicaid provider number

medicaidRecipientIdNumber · items[].planInformation.medicaidRecipientIdNumber · String

The Medicaid recipient identification number

medicalAssistanceCategory · items[].planInformation.medicalAssistanceCategory · String

The medical assistance category

medicalRecordIdentificationNumber · items[].planInformation.medicalRecordIdentificationNumber · String

The medical record identification number

medicareProviderNumber · items[].planInformation.medicareProviderNumber · String

The Medicare provider number

memberId · items[].planInformation.memberId · String

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

patientAccountNumber · items[].planInformation.patientAccountNumber · String

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

personalIdentificationNumber · items[].planInformation.personalIdentificationNumber · String

The personal identification number (PIN)

planDescription · items[].planInformation.planDescription · String

The plan description

planNetworkIdDescription · items[].planInformation.planNetworkIdDescription · String

The plan, group, or plan network name

planNetworkIdNumber · items[].planInformation.planNetworkIdNumber · String

The plan network identification number

planNumber · items[].planInformation.planNumber · String

The plan number

policyNumber · items[].planInformation.policyNumber · String

The group or policy number

priorAuthorizationNumber · items[].planInformation.priorAuthorizationNumber · String

The prior authorization number

priorIdNumber · items[].planInformation.priorIdNumber · String

The prior identifier number

referralNumber · items[].planInformation.referralNumber · String

The referral number

socialSecurityNumber · items[].planInformation.socialSecurityNumber · String

The social security number

stateLicenseNumber · items[].planInformation.stateLicenseNumber · String

The state license number

submitterIdentificationNumber · items[].planInformation.submitterIdentificationNumber · String

The submitter identification number

userIdentification · items[].planInformation.userIdentification · String

The user identification

provider · items[].provider · Object

Information about the provider who requested the insurance discovery check.

address · items[].provider.address · Object

The provider's contact information.

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

The first line of the address.

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

The second line of the address.

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

The city.

countryCode · items[].provider.address.countryCode · String Length: 2

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · items[].provider.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

entityIdentifier · items[].provider.entityIdentifier · String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

entityType · items[].provider.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

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

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

middleName · items[].provider.middleName · String

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

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

The provider's National Provider Identifier (NPI).

payorIdentification · items[].provider.payorIdentification · String

The Payor Identification.

pharmacyProcessorNumber · items[].provider.pharmacyProcessorNumber · String

The pharmacy processor number.

providerCode · items[].provider.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName · items[].provider.providerFirstName · String

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

providerName · items[].provider.providerName · String

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

providerOrgName · items[].provider.providerOrgName · String

The provider's organization name.

referenceIdentification · items[].provider.referenceIdentification · String

The Health Care Provider Taxonomy Code.

serviceProviderNumber · items[].provider.serviceProviderNumber · String

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

servicesPlanID · items[].provider.servicesPlanID · String

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

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

The Social Security Number (SSN).

suffix · items[].provider.suffix · String

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

subscriber · items[].subscriber · Object

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

address · items[].subscriber.address · Object

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

The first line of the address.

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

The second line of the address.

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

The city.

countryCode · items[].subscriber.address.countryCode · String Length: 2

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · items[].subscriber.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

birthSequenceNumber · items[].subscriber.birthSequenceNumber · String

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

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

The member's date of birth.

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

The military service date.

dateTimePeriodFormatQualifier · items[].subscriber.dateTimePeriodFormatQualifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

D8

RD8

description · items[].subscriber.description · String

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

employmentStatusCode · items[].subscriber.employmentStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AE

AO

AS

AT

AU

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

The military service end date.

entityIdentifier · items[].subscriber.entityIdentifier · String

The entity identifier for the subscriber.

Possible values

Insured or Subscriber

entityType · items[].subscriber.entityType · String

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

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

firstName · items[].subscriber.firstName · String

The member's first name.

gender · items[].subscriber.gender · String

Code indicating the patient's gender.

Possible values

M

F

U

governmentServiceAffiliationCode · items[].subscriber.governmentServiceAffiliationCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

groupDescription · items[].subscriber.groupDescription · String

Group name

groupNumber · items[].subscriber.groupNumber · String

The group number associated with the insurance policy.

healthCareDiagnosisCodes · items[].subscriber.healthCareDiagnosisCodes · Array of Objects

Information about the patient's healthcare diagnosis.

diagnosisCode · items[].subscriber.healthCareDiagnosisCodes[].diagnosisCode · String

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

diagnosisTypeCode · items[].subscriber.healthCareDiagnosisCodes[].diagnosisTypeCode · String

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

informationStatusCode · items[].subscriber.informationStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

C

L

O

P

insuredIndicator · items[].subscriber.insuredIndicator · String

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

Possible values

Y

lastName · items[].subscriber.lastName · String

The member's last name.

maintenanceReasonCode · items[].subscriber.maintenanceReasonCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

25

maintenanceTypeCode · items[].subscriber.maintenanceTypeCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

001

memberId · items[].subscriber.memberId · String

The member ID for the insurance policy.

middleName · items[].subscriber.middleName · String

The member's middle name or initial.

militaryServiceRankCode · items[].subscriber.militaryServiceRankCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A1

A2

A3

B1

B2

planDescription · items[].subscriber.planDescription · String

Plan name

planNetworkDescription · items[].subscriber.planNetworkDescription · String

Plan network name

planNetworkIdNumber · items[].subscriber.planNetworkIdNumber · String

The network identification number associated with the insurance policy.

planNumber · items[].subscriber.planNumber · String

The plan number associated with the insurance policy.

relationToSubscriber · items[].subscriber.relationToSubscriber · String

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

Possible values

Self

relationToSubscriberCode · items[].subscriber.relationToSubscriberCode · String

For the subscriber, this is always 18 for Self.

Possible values

18

responseProvider · items[].subscriber.responseProvider · Object

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

aaaErrors · items[].subscriber.responseProvider.aaaErrors · Array of Objects

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

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

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

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

The error description.

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

The error type, AAA.

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

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

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

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

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

Information to help you correct the error.

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

address · items[].subscriber.responseProvider.address · Object

The provider's contact information.

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

The first line of the address.

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

The second line of the address.

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

The city.

countryCode · items[].subscriber.responseProvider.address.countryCode · String Length: 2

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

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

The country subdivision code from Part 2 of ISO 3166.

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

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

state · items[].subscriber.responseProvider.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId · items[].subscriber.responseProvider.employersId · String Deprecated

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

entityIdentifier · items[].subscriber.responseProvider.entityIdentifier · String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

entityType · items[].subscriber.responseProvider.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

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

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

middleName · items[].subscriber.responseProvider.middleName · String

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

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

The provider's National Provider Identifier (NPI).

payorIdentification · items[].subscriber.responseProvider.payorIdentification · String

The Payor Identification.

pharmacyProcessorNumber · items[].subscriber.responseProvider.pharmacyProcessorNumber · String

The pharmacy processor number.

providerCode · items[].subscriber.responseProvider.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName · items[].subscriber.responseProvider.providerFirstName · String

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

providerName · items[].subscriber.responseProvider.providerName · String

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

providerOrgName · items[].subscriber.responseProvider.providerOrgName · String

The provider's organization name.

referenceIdentification · items[].subscriber.responseProvider.referenceIdentification · String

The Health Care Provider Taxonomy Code.

serviceProviderNumber · items[].subscriber.responseProvider.serviceProviderNumber · String

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

servicesPlanID · items[].subscriber.responseProvider.servicesPlanID · String

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

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

The Social Security Number (SSN).

suffix · items[].subscriber.responseProvider.suffix · String

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

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

The member's Social Security Number (SSN).

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

The military service start date.

suffix · items[].subscriber.suffix · String

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

uniqueHealthIdentifier · items[].subscriber.uniqueHealthIdentifier · String

The member's unique health identifier.

meta · Object

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

applicationMode · meta.applicationMode · String

The type of data in the request. This is always production.

Payers may sometimes return other non-compliant values.

Possible values

production

test

information

traceId · meta.traceId · String

The unique ID Stedi assigns to this request.

status · String

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.

Possible values

PENDING

COMPLETE

ERROR

Request

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 '{
    "encounter": {
      "beginningDateOfService": "20240326",
      "endDateOfService": "20240326"
    },
    "provider": {
      "npi": "1999999984"
    },
    "subscriber": {
      "address": {
        "address1": "123 Main St",
        "city": "Springfield",
        "postalCode": "62701",
        "state": "IL"
      },
      "dateOfBirth": "19800101",
      "firstName": "John",
      "gender": "M",
      "lastName": "Smith",
      "middleName": "Robert",
      "ssn": "123456789"
    }
  }'

Response

{
  "discoveryId": "12345678-abcd-4321-efgh-987654321abc",
  "items": [
    {
      "benefitsInformation": [
        {
          "additionalInformation": [
            {
              "description": "To determine if a prior authorization is required, please check the health plan's website."
            }
          ],
          "benefitsRelatedEntities": [
            {
              "entityFirstname": "Jane",
              "entityIdentification": "XX",
              "entityIdentificationValue": "1234567890",
              "entityIdentifier": "Primary Care Provider",
              "entityName": "Dough",
              "entityType": "Person"
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Not Applicable",
          "inPlanNetworkIndicatorCode": "W",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Not Applicable",
          "inPlanNetworkIndicatorCode": "W",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "1"
          ],
          "serviceTypes": [
            "Medical Care"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "4"
          ],
          "serviceTypes": [
            "Diagnostic X-Ray"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "4"
          ],
          "serviceTypes": [
            "Diagnostic X-Ray"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "4"
          ],
          "serviceTypes": [
            "Diagnostic X-Ray"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "5"
          ],
          "serviceTypes": [
            "Diagnostic Lab"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per visit"
            }
          ],
          "benefitAmount": "20",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "5"
          ],
          "serviceTypes": [
            "Diagnostic Lab"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "5"
          ],
          "serviceTypes": [
            "Diagnostic Lab"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "12"
          ],
          "serviceTypes": [
            "Durable Medical Equipment Purchase"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "12"
          ],
          "serviceTypes": [
            "Durable Medical Equipment Purchase"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "12"
          ],
          "serviceTypes": [
            "Durable Medical Equipment Purchase"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "13"
          ],
          "serviceTypes": [
            "Ambulatory Service Center Facility"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "13"
          ],
          "serviceTypes": [
            "Ambulatory Service Center Facility"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "13"
          ],
          "serviceTypes": [
            "Ambulatory Service Center Facility"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "18"
          ],
          "serviceTypes": [
            "Durable Medical Equipment Rental"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "18"
          ],
          "serviceTypes": [
            "Durable Medical Equipment Rental"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "18"
          ],
          "serviceTypes": [
            "Durable Medical Equipment Rental"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Limited to 26 visits per year (visits in excess of 26 require prior authorization)."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "33"
          ],
          "serviceTypes": [
            "Chiropractic"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "33"
          ],
          "serviceTypes": [
            "Chiropractic"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "33"
          ],
          "serviceTypes": [
            "Chiropractic"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "48"
          ],
          "serviceTypes": [
            "Hospital - Inpatient"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "48"
          ],
          "serviceTypes": [
            "Hospital - Inpatient"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "48"
          ],
          "serviceTypes": [
            "Hospital - Inpatient"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "50"
          ],
          "serviceTypes": [
            "Hospital - Outpatient"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "50"
          ],
          "serviceTypes": [
            "Hospital - Outpatient"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "50"
          ],
          "serviceTypes": [
            "Hospital - Outpatient"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "51"
          ],
          "serviceTypes": [
            "Hospital - Emergency Accident"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "51"
          ],
          "serviceTypes": [
            "Hospital - Emergency Accident"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "51"
          ],
          "serviceTypes": [
            "Hospital - Emergency Accident"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "51"
          ],
          "serviceTypes": [
            "Hospital - Emergency Accident"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "52"
          ],
          "serviceTypes": [
            "Hospital - Emergency Medical"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "52"
          ],
          "serviceTypes": [
            "Hospital - Emergency Medical"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "52"
          ],
          "serviceTypes": [
            "Hospital - Emergency Medical"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "52"
          ],
          "serviceTypes": [
            "Hospital - Emergency Medical"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "53"
          ],
          "serviceTypes": [
            "Hospital - Ambulatory Surgical"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "53"
          ],
          "serviceTypes": [
            "Hospital - Ambulatory Surgical"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "53"
          ],
          "serviceTypes": [
            "Hospital - Ambulatory Surgical"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "62"
          ],
          "serviceTypes": [
            "MRI/CAT Scan"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "62"
          ],
          "serviceTypes": [
            "MRI/CAT Scan"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "62"
          ],
          "serviceTypes": [
            "MRI/CAT Scan"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "65"
          ],
          "serviceTypes": [
            "Newborn Care"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "65"
          ],
          "serviceTypes": [
            "Newborn Care"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "65"
          ],
          "serviceTypes": [
            "Newborn Care"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Covered in accordance with ACA guidelines."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "68"
          ],
          "serviceTypes": [
            "Well Baby Care"
          ]
        },
        {
          "benefitAmount": "0",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "68"
          ],
          "serviceTypes": [
            "Well Baby Care"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "68"
          ],
          "serviceTypes": [
            "Well Baby Care"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "69"
          ],
          "serviceTypes": [
            "Maternity"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "69"
          ],
          "serviceTypes": [
            "Maternity"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "69"
          ],
          "serviceTypes": [
            "Maternity"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "86"
          ],
          "serviceTypes": [
            "Emergency Services"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "86"
          ],
          "serviceTypes": [
            "Emergency Services"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "86"
          ],
          "serviceTypes": [
            "Emergency Services"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "86"
          ],
          "serviceTypes": [
            "Emergency Services"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "88"
          ],
          "serviceTypes": [
            "Pharmacy"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per prescription"
            }
          ],
          "benefitAmount": "10",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "88"
          ],
          "serviceTypes": [
            "Pharmacy"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "88"
          ],
          "serviceTypes": [
            "Pharmacy"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "PCP"
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "98"
          ],
          "serviceTypes": [
            "Professional (Physician) Visit - Office"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per visit"
            },
            {
              "description": "PCP"
            }
          ],
          "benefitAmount": "15",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "98"
          ],
          "serviceTypes": [
            "Professional (Physician) Visit - Office"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "PCP"
            }
          ],
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "98"
          ],
          "serviceTypes": [
            "Professional (Physician) Visit - Office"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Specialist"
            },
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "98"
          ],
          "serviceTypes": [
            "Professional (Physician) Visit - Office"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per visit"
            },
            {
              "description": "Specialist"
            }
          ],
          "benefitAmount": "30",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "98"
          ],
          "serviceTypes": [
            "Professional (Physician) Visit - Office"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "Specialist"
            }
          ],
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "98"
          ],
          "serviceTypes": [
            "Professional (Physician) Visit - Office"
          ]
        },
        {
          "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"
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A4"
          ],
          "serviceTypes": [
            "Psychiatric"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A4"
          ],
          "serviceTypes": [
            "Psychiatric"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A4"
          ],
          "serviceTypes": [
            "Psychiatric"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A6"
          ],
          "serviceTypes": [
            "Psychotherapy"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A6"
          ],
          "serviceTypes": [
            "Psychotherapy"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A6"
          ],
          "serviceTypes": [
            "Psychotherapy"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A7"
          ],
          "serviceTypes": [
            "Psychiatric - Inpatient"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A7"
          ],
          "serviceTypes": [
            "Psychiatric - Inpatient"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A7"
          ],
          "serviceTypes": [
            "Psychiatric - Inpatient"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A8"
          ],
          "serviceTypes": [
            "Psychiatric - Outpatient"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A8"
          ],
          "serviceTypes": [
            "Psychiatric - Outpatient"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "A8"
          ],
          "serviceTypes": [
            "Psychiatric - Outpatient"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AD"
          ],
          "serviceTypes": [
            "Occupational Therapy"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AD"
          ],
          "serviceTypes": [
            "Occupational Therapy"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AD"
          ],
          "serviceTypes": [
            "Occupational Therapy"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AF"
          ],
          "serviceTypes": [
            "Speech Therapy"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AF"
          ],
          "serviceTypes": [
            "Speech Therapy"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AF"
          ],
          "serviceTypes": [
            "Speech Therapy"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Limited to 150 days per year."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AG"
          ],
          "serviceTypes": [
            "Skilled Nursing Care"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AG"
          ],
          "serviceTypes": [
            "Skilled Nursing Care"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "AG"
          ],
          "serviceTypes": [
            "Skilled Nursing Care"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Covered in accordance with ACA guidelines."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "BZ"
          ],
          "serviceTypes": [
            "Physician Visit - Office: Well"
          ]
        },
        {
          "benefitAmount": "0",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "BZ"
          ],
          "serviceTypes": [
            "Physician Visit - Office: Well"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "BZ"
          ],
          "serviceTypes": [
            "Physician Visit - Office: Well"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "MH"
          ],
          "serviceTypes": [
            "Mental Health"
          ]
        },
        {
          "benefitPercent": "0.5",
          "code": "A",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Insurance",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "MH"
          ],
          "serviceTypes": [
            "Mental Health"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "MH"
          ],
          "serviceTypes": [
            "Mental Health"
          ]
        },
        {
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "PT"
          ],
          "serviceTypes": [
            "Physical Therapy"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per visit"
            }
          ],
          "benefitAmount": "15",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "PT"
          ],
          "serviceTypes": [
            "Physical Therapy"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "code": "I",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Non-Covered",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "PT"
          ],
          "serviceTypes": [
            "Physical Therapy"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "UC"
          ],
          "serviceTypes": [
            "Urgent Care"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per visit"
            }
          ],
          "benefitAmount": "10",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "UC"
          ],
          "serviceTypes": [
            "Urgent Care"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "additionalInformation": [
            {
              "description": "Covered No Limit."
            }
          ],
          "code": "1",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "UC"
          ],
          "serviceTypes": [
            "Urgent Care"
          ]
        },
        {
          "additionalInformation": [
            {
              "description": "per visit"
            }
          ],
          "benefitAmount": "10",
          "code": "B",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Co-Payment",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "UC"
          ],
          "serviceTypes": [
            "Urgent Care"
          ],
          "timeQualifier": "Visit",
          "timeQualifierCode": "27"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "0",
          "code": "C",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Deductible",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "3000",
          "code": "G",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "2000",
          "code": "G",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "6000",
          "code": "G",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "5000",
          "code": "G",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "Yes",
          "inPlanNetworkIndicatorCode": "Y",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
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          ],
          "serviceTypes": [
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          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "0",
          "code": "G",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
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          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "0",
          "code": "G",
          "coverageLevel": "Individual",
          "coverageLevelCode": "IND",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
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          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        },
        {
          "benefitAmount": "0",
          "code": "G",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
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          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Calendar Year",
          "timeQualifierCode": "23"
        },
        {
          "benefitAmount": "0",
          "code": "G",
          "coverageLevel": "Family",
          "coverageLevelCode": "FAM",
          "inPlanNetworkIndicator": "No",
          "inPlanNetworkIndicatorCode": "N",
          "name": "Out of Pocket (Stop Loss)",
          "planCoverage": "Gold Plan",
          "serviceTypeCodes": [
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          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "timeQualifier": "Remaining",
          "timeQualifierCode": "29"
        }
      ],
      "confidence": {
        "level": "REVIEW_NEEDED",
        "reason": "This record was identified as a low confidence match due to a DOB partial match"
      },
      "payer": {
        "name": "EXAMPLE INSURANCE CO"
      },
      "planDateInformation": {
        "eligibilityBegin": "20250101",
        "planBegin": "20250101",
        "service": "20250301"
      },
      "planInformation": {
        "groupDescription": "Individual On-Exchange",
        "groupNumber": "123456-78",
        "planNumber": "123456-EXMPL9876"
      },
      "provider": {
        "entityType": "Non-Person Entity",
        "npi": "1999999984",
        "providerName": "provider"
      },
      "subscriber": {
        "address": {
          "address1": "123 Main Street",
          "city": "ANYTOWN",
          "postalCode": "12345",
          "state": "CA"
        },
        "dateOfBirth": "19900115",
        "firstName": "John",
        "gender": "M",
        "groupDescription": "Individual On-Exchange",
        "groupNumber": "123456-78",
        "lastName": "Doe",
        "memberId": "987654321000",
        "middleName": "Smith",
        "planNumber": "123456-EXMPL9876"
      }
    }
  ],
  "meta": {
    "applicationMode": "production",
    "traceId": "1-abcdef12-123456789abcdef123456789"
  },
  "status": "COMPLETE"
}