Insurance Discovery Check

POST

insurance-discovery

check

curl --request POST \
  --url https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1 \
  --header 'Authorization: <api-key>' \
  --header 'Content-Type: application/json' \
  --data '{
  "provider": {
    "npi": "1234567890"
  },
  "subscriber": {
    "firstName": "John",
    "lastName": "Smith",
    "middleName": "Robert",
    "dateOfBirth": "19800101",
    "ssn": "123456789",
    "gender": "M",
    "address": {
      "address1": "123 Main St",
      "city": "Springfield",
      "state": "IL",
      "postalCode": "62701"
    }
  },
  "encounter": {
    "beginningDateOfService": "20240326",
    "endDateOfService": "20240326"
  }
}'

{
  "discoveryId": "12345678-abcd-4321-efgh-987654321abc",
  "items": [
    {
      "provider": {
        "providerName": "provider",
        "entityType": "Non-Person Entity",
        "npi": "1234567890"
      },
      "subscriber": {
        "memberId": "987654321000",
        "firstName": "John",
        "lastName": "Doe",
        "middleName": "Smith",
        "gender": "M",
        "dateOfBirth": "19900115",
        "groupNumber": "123456-78",
        "planNumber": "123456-EXMPL9876",
        "groupDescription": "Individual On-Exchange",
        "address": {
          "address1": "123 Main Street",
          "city": "ANYTOWN",
          "state": "CA",
          "postalCode": "12345"
        }
      },
      "payer": {
        "name": "EXAMPLE INSURANCE CO"
      },
      "planInformation": {
        "planNumber": "123456-EXMPL9876",
        "groupNumber": "123456-78",
        "groupDescription": "Individual On-Exchange"
      },
      "planDateInformation": {
        "planBegin": "20250101",
        "eligibilityBegin": "20250101",
        "service": "20250301"
      },
      "benefitsInformation": [
        {
          "inPlanNetworkIndicatorCode": "W",
          "benefitsRelatedEntities": [
            {
              "entityIdentifier": "Primary Care Provider",
              "entityIdentification": "XX",
              "entityName": "Dough",
              "entityIdentificationValue": "1234567890",
              "entityFirstname": "Jane",
              "entityType": "Person"
            }
          ],
          "additionalInformation": [
            {
              "description": "To determine if a prior authorization is required, please check the health plan's website."
            }
          ],
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "inPlanNetworkIndicator": "Not Applicable",
          "name": "Active Coverage",
          "code": "1",
          "planCoverage": "Gold Plan"
        },
        {
          "serviceTypes": [
            "Medical Care"
          ],
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "inPlanNetworkIndicatorCode": "W",
          "serviceTypeCodes": [
            "1"
          ],
          "inPlanNetworkIndicator": "Not Applicable",
          "code": "1"
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "inPlanNetworkIndicatorCode": "Y",
          "code": "1",
          "name": "Active Coverage",
          "serviceTypeCodes": [
            "4"
          ],
          "serviceTypes": [
            "Diagnostic X-Ray"
          ],
          "inPlanNetworkIndicator": "Yes",
          "planCoverage": "Gold Plan"
        },
        {
          "inPlanNetworkIndicator": "Yes",
          "code": "A",
          "serviceTypeCodes": [
            "4"
          ],
          "name": "Co-Insurance",
          "coverageLevel": "Family",
          "serviceTypes": [
            "Diagnostic X-Ray"
          ],
          "inPlanNetworkIndicatorCode": "Y",
          "benefitPercent": "0.5",
          "planCoverage": "Gold Plan",
          "timeQualifierCode": "27",
          "timeQualifier": "Visit",
          "coverageLevelCode": "FAM"
        }
      ],
      "confidence": {
        "score": 0.8,
        "level": "REVIEW_NEEDED",
        "reason": "This record was identified as a low confidence match due to a DOB partial match"
      }
    }
  ],
  "meta": {
    "applicationMode": "production",
    "traceId": "1-abcdef12-123456789abcdef123456789"
  },
  "status": "COMPLETE"
}

This is a beta endpoint. We may make backward incompatible changes.

This endpoint submits an insurance discovery check request for a patient. You can use an insurance discovery check to find a patient’s active coverage using only their demographic data.

You may need to perform an insurance discovery check when a patient provides outdated insurance details, doesn’t have their insurance card, or can’t provide insurance details in an urgent care situation. You may also want to use insurance discovery checks to simplify patient onboarding by reducing the amount of information new patients must provide to schedule an appointment.

Call this endpoint with as much patient demographic information as possible to increase the chances of finding matching coverage. You’ll also need to include information like the provider’s NPI and the service date, similar to an eligibility check.
Stedi uses the demographic information you provide to determine if the patient has active coverage with one or more payers. This process involves submitting real-time eligibility checks to supported payers in order to find a match.
When the insurance discovery check is complete, Stedi returns an array of potential active coverages along with subscriber details and complete benefits information. Results will typically also contain a confidence score to indicate how likely it is that the plan is a match for the patient information you provided, but this won’t happen in all circumstances.

You should always review the results to ensure the returned subscriber information for each active health plan matches the demographic information for the patient. You generally shouldn’t need to perform a followup standard eligibility check, since the insurance discovery check includes all of the information that would be included in a standard eligibility check.

There is no cost for limited insurance discovery checks while the API is in beta. If you are interested in pricing when the product is generally available, please reach out to the Stedi team.

Enrollment requirements

You should submit a transaction enrollment request for each provider for whom you plan to submit insurance discovery checks. To enroll your providers, please download the enrollment spreadsheet template and add one row for each provider. You’ll be required to provide the following information:

National Provider Identifier (NPI)
Tax Identification Number (TIN)
Medicaid Provider ID (if applicable)

You can email the completed template to enrollments@stedi.com, or drop it in your shared Slack channel.

Response

This endpoint can take up to 120 seconds to return a response, though it’s often faster.

The response can have one of two status values:

COMPLETE - Stedi has completed the insurance discovery search for the patient. If Stedi finds coverage for the patient, the items array will contain the results. If Stedi doesn’t find any coverage for the patient, the items array will be empty.
PENDING - Stedi is still processing the insurance discovery search for the patient. You can use the discoveryId in the response to retrieve the results asynchronously.

Retrieve results asynchronously

If the synchronous insurance discovery response indicates that the search is still PENDING, you can use the discoveryId to retrieve the complete results asynchronously from the Insurance Discovery Check Results endpoint.

Authorizations

Authorization

string

header

required

A Stedi API Key for authentication.

Body

application/json

provider

object

required

Information about the provider requesting the insurance discovery check.

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.

subscriber.firstName

string

required

The subscriber's first name.

Required string length: 1 - 25

subscriber.lastName

string

required

The subscriber's last name.

Required string length: 1 - 25

subscriber.middleName

string

The subscriber's middle name or initial.

Required string length: 1 - 25

subscriber.dateOfBirth

string

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

subscriber.ssn

string

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

Required string length: 1 - 11

subscriber.gender

enum<string>

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

Available options:

M,

F

subscriber.address

object

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

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.

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), the Stedi defaults to the current date.

If you need to specify a single date, use the beginningDateOfService property and leave endDateOfService blank.

Response

200

application/json

InsuranceDiscoveryCheck 200 response

meta

object

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

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.

status

enum<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.

Available options:

PENDING,

COMPLETE

items

object[]

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.

items.provider

object

Information about the provider who requested the insurance discovery check.

items.provider.providerName

string

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

items.provider.providerFirstName

string

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

items.provider.providerOrgName

string

The provider's organization name.

items.provider.middleName

string

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

items.provider.suffix

string

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

items.provider.entityIdentifier

enum<string>

A code identifying the type of provider.

Available options:

Provider,

Third-Party Administrator,

Employer,

Hospital,

Facility,

Gateway Provider,

Plan Sponsor,

Payer,

Unknown

items.provider.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

items.provider.npi

string

The provider's National Provider Identifier (NPI).

items.provider.providerCode

enum<string>

A code that communicates the provider's role in the type of benefits information in the response.

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SB,

SK,

SU,

Unknown

items.provider.referenceIdentification

string

The Health Care Provider Taxonomy Code.

items.provider.ssn

string

The Social Security Number (SSN).

items.provider.federalTaxpayersIdNumber

string

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

items.provider.payorIdentification

string

The Payor Identification.

items.provider.pharmacyProcessorNumber

string

The pharmacy processor number.

items.provider.serviceProviderNumber

string

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

items.provider.servicesPlanID

string

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

items.provider.address

object

The provider's contact information.

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.

items.subscriber.healthCareDiagnosisCodes

object[]

Information about the patient's healthcare diagnosis.

items.subscriber.memberId

string

The member ID for the subscriber's insurance policy.

items.subscriber.firstName

string

The subscriber's first name.

items.subscriber.lastName

string

The subscriber's last name.

items.subscriber.middleName

string

The subscriber's middle name or initial.

items.subscriber.suffix

string

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

items.subscriber.gender

enum<string>

Code indicating the patient's gender. Can be F - Female, M - Male, or U - Unknown.

Available options:

M,

F,

U

items.subscriber.entityIdentifier

enum<string>

The entity identifier for the subscriber.

Available options:

Insured or Subscriber

items.subscriber.entityType

enum<string>

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

Available options:

Person,

Non-Person Entity

items.subscriber.uniqueHealthIdentifier

string

The subscriber's unique health identifier.

items.subscriber.dateOfBirth

string

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

items.subscriber.informationStatusCode

enum<string>

The status of the subscriber's information, used to report military service data.

Available options:

A,

C,

L,

O,

P,

S,

T,

Unknown

items.subscriber.employmentStatusCode

enum<string>

The subscriber's employment status code, used to report military service data.

Available options:

AE,

AO,

AS,

AT,

AU,

CC,

DD,

HD,

IR,

LX,

PE,

RE,

RM,

RR,

RU,

Unknown

items.subscriber.governmentServiceAffiliationCode

enum<string>

The subscriber's government service affiliation code, used to report military service data.

Available options:

A,

B,

C,

D,

E,

F,

G,

H,

I,

J,

K,

L,

M,

N,

O,

Q,

R,

S,

U,

W,

Unknown

items.subscriber.description

string

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

items.subscriber.militaryServiceRankCode

enum<string>

The subscriber's military service rank code.

Available options:

A1,

A2,

A3,

B1,

B2,

C1,

C2,

C3,

C4,

C5,

C6,

C7,

C8,

C9,

E1,

F1,

F2,

F3,

F4,

G1,

G4,

L1,

L2,

L3,

L4,

L5,

L6,

M1,

M2,

M3,

M4,

M5,

M6,

P1,

P2,

P3,

P4,

P5,

R1,

R2,

S1,

S2,

S3,

S4,

S5,

S6,

S7,

S8,

S9,

SA,

SB,

SC,

T1,

V1,

W1,

Unknown

items.subscriber.dateTimePeriodFormatQualifier

enum<string>

The format of the military service date and time period.

Available options:

D8,

RD8

items.subscriber.dateTimePeriod

string

The military service date, formatted as YYYYMMDD.

items.subscriber.startDateTimePeriod

string

The military service start date, formatted as YYYYMMDD.

items.subscriber.endDateTimePeriod

string

The military service end date, formatted as YYYYMMDD.

items.subscriber.ssn

string

The subscriber's Social Security Number (SSN).

items.subscriber.groupNumber

string

The group number associated with the subscriber's insurance policy.

items.subscriber.planNumber

string

The plan number associated with the subscriber's insurance policy.

items.subscriber.planNetworkIdNumber

string

The network identification number associated with the subscriber's insurance policy.

items.subscriber.groupDescription

string

Group name

items.subscriber.planDescription

string

Plan name

items.subscriber.planNetworkDescription

string

Plan network name

items.subscriber.relationToSubscriber

enum<string>

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

Available options:

Self

items.subscriber.relationToSubscriberCode

enum<string>

For the subscriber, this is always 18 for Self.

Available options:

18

items.subscriber.insuredIndicator

enum<string>

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

Available options:

Y

items.subscriber.maintenanceTypeCode

enum<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

Available options:

001

items.subscriber.maintenanceReasonCode

enum<string>

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

Available options:

25

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.

items.subscriber.address

object

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.

items.subscriber.responseProvider.providerName

string

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

items.subscriber.responseProvider.providerFirstName

string

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

items.subscriber.responseProvider.providerOrgName

string

The provider's organization name.

items.subscriber.responseProvider.middleName

string

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

items.subscriber.responseProvider.suffix

string

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

items.subscriber.responseProvider.entityIdentifier

enum<string>

A code identifying the type of provider.

Available options:

Provider,

Third-Party Administrator,

Employer,

Hospital,

Facility,

Gateway Provider,

Plan Sponsor,

Payer,

Unknown

items.subscriber.responseProvider.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

items.subscriber.responseProvider.npi

string

The provider's National Provider Identifier (NPI).

items.subscriber.responseProvider.providerCode

enum<string>

A code that communicates the provider's role in the type of benefits information in the response.

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SB,

SK,

SU,

Unknown

items.subscriber.responseProvider.referenceIdentification

string

The Health Care Provider Taxonomy Code.

items.subscriber.responseProvider.ssn

string

The Social Security Number (SSN).

items.subscriber.responseProvider.federalTaxpayersIdNumber

string

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

items.subscriber.responseProvider.payorIdentification

string

The Payor Identification.

items.subscriber.responseProvider.pharmacyProcessorNumber

string

The pharmacy processor number.

items.subscriber.responseProvider.serviceProviderNumber

string

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

items.subscriber.responseProvider.servicesPlanID

string

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

items.subscriber.responseProvider.address

object

The provider's contact information.

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.

items.subscriber.responseProvider.aaaErrors

object[]

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

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.

items.dependent.healthCareDiagnosisCodes

object[]

Information about the patient's healthcare diagnosis.

items.dependent.memberId

string

The member ID for the subscriber's insurance policy.

items.dependent.firstName

string

The dependent's first name.

items.dependent.lastName

string

The dependent's last name.

items.dependent.middleName

string

The dependent's middle name or initial.

items.dependent.suffix

string

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

items.dependent.gender

enum<string>

Code indicating the patient's gender. Can be F - Female, M - Male, or U - Unknown.

Available options:

M,

F,

U

items.dependent.entityIdentifier

enum<string>

The entity identifier for the dependent.

Available options:

Dependent

items.dependent.entityType

enum<string>

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

Available options:

Person,

Non-Person Entity

items.dependent.uniqueHealthIdentifier

string

The dependent's unique health identifier.

items.dependent.dateOfBirth

string

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

items.dependent.informationStatusCode

enum<string>

The status of the dependent's information, used to report military service data.

Available options:

A,

C,

L,

O,

P,

S,

T,

Unknown

items.dependent.employmentStatusCode

enum<string>

The dependent's employment status code, used to report military service data.

Available options:

AE,

AO,

AS,

AT,

AU,

CC,

DD,

HD,

IR,

LX,

PE,

RE,

RM,

RR,

RU,

Unknown

items.dependent.governmentServiceAffiliationCode

enum<string>

The dependent's government service affiliation code, used to report military service data.

Available options:

A,

B,

C,

D,

E,

F,

G,

H,

I,

J,

K,

L,

M,

N,

O,

Q,

R,

S,

U,

W,

Unknown

items.dependent.description

string

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

items.dependent.militaryServiceRankCode

enum<string>

The dependent's military service rank code.

Available options:

A1,

A2,

A3,

B1,

B2,

C1,

C2,

C3,

C4,

C5,

C6,

C7,

C8,

C9,

E1,

F1,

F2,

F3,

F4,

G1,

G4,

L1,

L2,

L3,

L4,

L5,

L6,

M1,

M2,

M3,

M4,

M5,

M6,

P1,

P2,

P3,

P4,

P5,

R1,

R2,

S1,

S2,

S3,

S4,

S5,

S6,

S7,

S8,

S9,

SA,

SB,

SC,

T1,

V1,

W1,

Unknown

items.dependent.dateTimePeriodFormatQualifier

enum<string>

The format of the military service date and time period.

Available options:

D8,

RD8

items.dependent.dateTimePeriod

string

The military service date, formatted as YYYYMMDD.

items.dependent.startDateTimePeriod

string

The military service start date, formatted as YYYYMMDD.

items.dependent.endDateTimePeriod

string

The military service end date, formatted as YYYYMMDD.

items.dependent.ssn

string

The dependent's Social Security Number (SSN).

items.dependent.groupNumber

string

The group number associated with the subscriber's insurance policy.

items.dependent.planNumber

string

The plan number associated with the subscriber's insurance policy.

items.dependent.planNetworkIdNumber

string

The network identification number associated with the subscriber's insurance policy.

items.dependent.groupDescription

string

Group name

items.dependent.planDescription

string

Plan name

items.dependent.planNetworkDescription

string

Plan network name

items.dependent.relationToSubscriber

enum<string>

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

Available options:

Spouse,

Child,

Employee,

Unknown,

Organ Donor,

Cadaver Donor,

Life Partner,

Other Relationship

items.dependent.relationToSubscriberCode

enum<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.

Available options:

01,

19,

20,

21,

39,

40,

53,

G8,

Unknown

items.dependent.insuredIndicator

enum<string>

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

Available options:

N

items.dependent.maintenanceTypeCode

enum<string>

Available options:

001

items.dependent.maintenanceReasonCode

enum<string>

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

Available options:

25

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.

items.dependent.address

object

items.dependent.responseProvider

object

items.dependent.responseProvider.providerName

string

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

items.dependent.responseProvider.providerFirstName

string

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

items.dependent.responseProvider.providerOrgName

string

The provider's organization name.

items.dependent.responseProvider.middleName

string

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

items.dependent.responseProvider.suffix

string

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

items.dependent.responseProvider.entityIdentifier

enum<string>

A code identifying the type of provider.

Available options:

Provider,

Third-Party Administrator,

Employer,

Hospital,

Facility,

Gateway Provider,

Plan Sponsor,

Payer,

Unknown

items.dependent.responseProvider.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

items.dependent.responseProvider.npi

string

The provider's National Provider Identifier (NPI).

items.dependent.responseProvider.providerCode

enum<string>

A code that communicates the provider's role in the type of benefits information in the response.

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SB,

SK,

SU,

Unknown

items.dependent.responseProvider.referenceIdentification

string

The Health Care Provider Taxonomy Code.

items.dependent.responseProvider.ssn

string

The Social Security Number (SSN).

items.dependent.responseProvider.federalTaxpayersIdNumber

string

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

items.dependent.responseProvider.payorIdentification

string

The Payor Identification.

items.dependent.responseProvider.pharmacyProcessorNumber

string

The pharmacy processor number.

items.dependent.responseProvider.serviceProviderNumber

string

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

items.dependent.responseProvider.servicesPlanID

string

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

items.dependent.responseProvider.address

object

The provider's contact information.

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.

items.dependent.responseProvider.aaaErrors

object[]

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.

items.payer.entityIdentifier

enum<string>

The entity identifier code for the payer.

Available options:

Third-Party Administrator,

Employer,

Gateway Provider,

Plan Sponsor,

Payer

items.payer.entityType

enum<string>

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

Available options:

Person,

Non-Person Entity

items.payer.firstName

string

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

items.payer.lastName

string

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

items.payer.name

string

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

items.payer.middleName

string

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

items.payer.suffix

string

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

items.payer.federalTaxpayersIdNumber

string

The payer's federal taxpayer's identification number.

items.payer.naic

string

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

items.payer.npi

string

The payer's National Provider Identifier (NPI).

items.payer.centersForMedicareAndMedicaidPlanId

string

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

items.payer.payorIdentification

string

The payor identification.

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.

items.payer.etin

string

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

items.planInformation

object

Additional identification for the patient's health plan.

items.planInformation.stateLicenseNumber

string

The state license number

items.planInformation.medicareProviderNumber

string

The Medicare provider number

items.planInformation.medicaidProviderNumber

string

The Medicaid provider number

items.planInformation.facilityIdNumber

string

The facility ID number

items.planInformation.personalIdentificationNumber

string

The personal identification number (PIN)

items.planInformation.planNumber

string

The plan number

items.planInformation.planDescription

string

The plan description

items.planInformation.policyNumber

string

The group or policy number

items.planInformation.memberId

string

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

items.planInformation.caseNumber

string

The case number

items.planInformation.familyUnitNumber

string

The family unit number

items.planInformation.groupNumber

string

The group number

items.planInformation.groupDescription

string

The group description

items.planInformation.referralNumber

string

The referral number

items.planInformation.alternativeListId

string

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

items.planInformation.classOfContractCode

string

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

items.planInformation.coverageListId

string

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

items.planInformation.contractNumber

string

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

items.planInformation.medicalRecordIdentificationNumber

string

The medical record identification number

items.planInformation.electronicDevicePin

string

The electronic device pin number

items.planInformation.submitterIdentificationNumber

string

The submitter identification number

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.

items.planInformation.hicNumber

string

The health insurance claim number

items.planInformation.drugFormularyNumber

string

The drug formulary number

items.planInformation.priorAuthorizationNumber

string

The prior authorization number

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.

items.planInformation.idCardNumber

string

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

items.planInformation.centersForMedicareAndMedicaidServicesNPI

string

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

items.planInformation.issueNumber

string

The issue number

items.planInformation.insurancePolicyNumber

string

The insurance policy number

items.planInformation.userIdentification

string

The user identification

items.planInformation.medicalAssistanceCategory

string

The medical assistance category

items.planInformation.eligibilityCategory

string

The eligibility category

items.planInformation.planNetworkIdNumber

string

The plan network identification number

items.planInformation.planNetworkIdDescription

string

The plan, group, or plan network name

items.planInformation.facilityNetworkIdentificationNumber

string

The facility network identification number

items.planInformation.medicaidRecipientIdNumber

string

The Medicaid recipient identification number

items.planInformation.priorIdNumber

string

The prior identifier number

The social security number

items.planInformation.federalTaxpayersIdentificationNumber

string

The federal taxpayer's identification number

items.planInformation.agencyClaimNumber

string

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

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.

items.planDateInformation.discharge

string

The discharge date.

items.planDateInformation.issue

string

The issue date.

items.planDateInformation.effectiveDateOfChange

string

The effective date of change.

items.planDateInformation.plan

string

Plan effective dates. Can be formatted as a single date (YYYYMMDD) or as a range of dates in YYYYMMDD-YYYYMMDD format.

items.planDateInformation.eligibility

string

Plan eligibility dates. Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.

items.planDateInformation.added

string

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

items.planDateInformation.cobraBegin

string

The date when COBRA coverage begins.

items.planDateInformation.cobraEnd

string

The date when COBRA coverage ends.

items.planDateInformation.premiumPaidToDateBegin

string

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

items.planDateInformation.premiumPaidToDateEnd

string

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

items.planDateInformation.planBegin

string

The date coverage from the plan begins. Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.

items.planDateInformation.planEnd

string

The date coverage from the plan ends.

items.planDateInformation.eligibilityBegin

string

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

items.planDateInformation.eligibilityEnd

string

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

items.planDateInformation.enrollment

string

The date when the patient is enrolled in the plan.

items.planDateInformation.admission

string

The admission date or dates. Formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges).

items.planDateInformation.dateOfDeath

string

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

items.planDateInformation.certification

string

The certification date.

items.planDateInformation.service

string

The service date or dates. Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.

items.planDateInformation.policyEffective

string

The date when the policy becomes effective.

items.planDateInformation.policyExpiration

string

The date when the policy expires.

items.planDateInformation.dateOfLastUpdate

string

The date when the plan information was last updated.

items.planDateInformation.status

string

The status date.

items.benefitsInformation

object[]

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

items.benefitsInformation.code

enum<string>

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

Available options:

1,

2,

3,

4,

5,

6,

7,

8,

A,

B,

C,

CB,

D,

E,

F,

G,

H,

I,

J,

K,

L,

M,

MC,

N,

O,

P,

Q,

R,

S,

T,

U,

V,

W,

X,

Y,

Unknown

items.benefitsInformation.name

enum<string>

The full name of the benefits information code.

Available options:

Active Coverage,

Active - Full Risk Capitation,

Active - Services Capitated,

Active - Services Capitated to Primary Care Physician,

Active - Pending Investigation,

Inactive,

Inactive - Pending Eligibility Update,

Inactive - Pending Investigation,

Co-Insurance,

Co-Payment,

Deductible,

Coverage Basis,

Benefit Description,

Exclusions,

Limitations,

Out of Pocket (Stop Loss),

Unlimited,

Non-Covered,

Cost Containment,

Reserve,

Primary Care Provider,

Pre-existing Condition,

Managed Care Coordinator,

Services Restricted to Following Provider,

Not Deemed a Medical Necessity,

Benefit Disclaimer,

Second Surgical Opinion Required,

Other or Additional Payor,

Prior Year(s) History,

Card(s) Reported Lost/Stolen,

Contact Following Entity for Eligibility or Benefit Information,

Cannot Process,

Other Source of Data,

Health Care Facility,

Spend Down,

Unknown

items.benefitsInformation.coverageLevelCode

enum<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.

Available options:

CHD,

DEP,

ECH,

EMP,

ESP,

FAM,

IND,

SPC,

SPO,

Unknown

items.benefitsInformation.coverageLevel

enum<string>

The full name of the coverage level code.

Available options:

Children Only,

Dependents Only,

Employee and Children,

Employee Only,

Employee and Spouse,

Family,

Individual,

Spouse and Children,

Spouse Only,

Unknown

items.benefitsInformation.serviceTypeCodes

enum<string>[]

Codes identifying the type of services. For example, 7 - Anesthesia. Visit Service Type Codes for a complete list.

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

Available options:

1,

2,

3,

4,

5,

6,

7,

8,

9,

10,

11,

12,

13,

14,

15,

16,

17,

18,

19,

20,

21,

22,

23,

24,

25,

26,

27,

28,

30,

32,

33,

34,

35,

36,

37,

38,

39,

40,

41,

42,

43,

44,

45,

46,

47,

48,

49,

50,

51,

52,

53,

54,

55,

56,

57,

58,

59,

60,

61,

62,

63,

64,

65,

66,

67,

68,

69,

70,

71,

72,

73,

74,

75,

76,

77,

78,

79,

80,

81,

82,

83,

84,

85,

86,

87,

88,

89,

90,

91,

92,

93,

94,

95,

96,

97,

98,

99,

A0,

A1,

A2,

A3,

A4,

A5,

A6,

A7,

A8,

A9,

AA,

AB,

AC,

AD,

AE,

AF,

AG,

AH,

AI,

AJ,

AK,

AL,

AM,

AN,

AO,

AQ,

AR,

B1,

B2,

B3,

BA,

BB,

BC,

BD,

BE,

BF,

BG,

BH,

BI,

BJ,

BK,

BL,

BM,

BN,

BP,

BQ,

BR,

BS,

BT,

BU,

BV,

BW,

BX,

BY,

BZ,

C1,

CA,

CB,

CC,

CD,

CE,

CF,

CG,

CH,

CI,

CJ,

CK,

CL,

CM,

CN,

CO,

CP,

CQ,

DG,

DM,

DS,

GF,

GN,

GY,

IC,

MH,

NI,

ON,

PT,

PU,

RN,

RT,

TC,

TN,

UC,

Unknown

items.benefitsInformation.serviceTypes

enum<string>[]

Available options:

Medical Care,

Surgical,

Consultation,

Diagnostic X-Ray,

Diagnostic Lab,

Radiation Therapy,

Anesthesia,

Surgical Assistance,

Other Medical,

Blood Charges,

Used Durable Medical Equipment,

Durable Medical Equipment Purchase,

Ambulatory Service Center Facility,

Renal Supplies in the Home,

Alternate Method Dialysis,

Chronic Renal Disease (CRD) Equipment,

Pre-Admission Testing,

Durable Medical Equipment Rental,

Pneumonia Vaccine,

Second Surgical Opinion,

Third Surgical Opinion,

Social Work,

Diagnostic Dental,

Periodontics,

Restorative,

Endodontics,

Maxillofacial Prosthetics,

Adjunctive Dental Services,

Health Benefit Plan Coverage,

Plan Waiting Period,

Chiropractic,

Chiropractic Office Visits,

Dental Care,

Dental Crowns,

Dental Accident,

Orthodontics,

Prosthodontics,

Oral Surgery,

Routine (Preventive) Dental,

Home Health Care,

Home Health Prescriptions,

Home Health Visits,

Hospice,

Respite Care,

Hospital,

Hospital - Inpatient,

Hospital - Room and Board,

Hospital - Outpatient,

Hospital - Emergency Accident,

Hospital - Emergency Medical,

Hospital - Ambulatory Surgical,

Long Term Care,

Major Medical,

Medically Related Transportation,

Air Transportation,

Cabulance,

Licensed Ambulance,

General Benefits,

In-vitro Fertilization,

MRI/CAT Scan,

Donor Procedures,

Acupuncture,

Newborn Care,

Pathology,

Smoking Cessation,

Well Baby Care,

Maternity,

Transplants,

Audiology Exam,

Inhalation Therapy,

Diagnostic Medical,

Private Duty Nursing,

Prosthetic Device,

Dialysis,

Otological Exam,

Chemotherapy,

Allergy Testing,

Immunizations,

Routine Physical,

Family Planning,

Infertility,

Abortion,

AIDS,

Emergency Services,

Cancer,

Pharmacy,

Free Standing Prescription Drug,

Mail Order Prescription Drug,

Brand Name Prescription Drug,

Generic Prescription Drug,

Podiatry,

Podiatry - Office Visits,

Podiatry - Nursing Home Visits,

Professional (Physician),

Anesthesiologist,

Professional (Physician) Visit - Office,

Professional (Physician) Visit - Inpatient,

Professional (Physician) Visit - Outpatient,

Professional (Physician) Visit - Nursing Home,

Professional (Physician) Visit - Skilled Nursing Facility,

Professional (Physician) Visit - Home,

Psychiatric,

Psychiatric - Room and Board,

Psychotherapy,

Psychiatric - Inpatient,

Psychiatric - Outpatient,

Rehabilitation,

Rehabilitation - Room and Board,

Rehabilitation - Inpatient,

Rehabilitation - Outpatient,

Occupational Therapy,

Physical Medicine,

Speech Therapy,

Skilled Nursing Care,

Skilled Nursing Care - Room and Board,

Substance Abuse,

Alcoholism,

Drug Addiction,

Vision (Optometry),

Frames,

Routine Exam,

Lenses,

Nonmedically Necessary Physical,

Experimental Drug Therapy,

Burn Care,

Brand Name Prescription Drug - Formulary,

Brand Name Prescription Drug - Non-Formulary,

Independent Medical Evaluation,

Partial Hospitalization (Psychiatric),

Day Care (Psychiatric),

Cognitive Therapy,

Massage Therapy,

Pulmonary Rehabilitation,

Cardiac Rehabilitation,

Pediatric,

Nursery,

Skin,

Orthopedic,

Cardiac,

Lymphatic,

Gastrointestinal,

Endocrine,

Neurology,

Eye,

Invasive Procedures,

Gynecological,

Obstetrical,

Obstetrical/Gynecological,

Mail Order Prescription Drug - Formulary,

Mail Order Prescription Drug - Non-Formulary,

Physician Visit - Office: Sick,

Physician Visit - Office: Well,

Coronary Care,

Private Duty Nursing - Inpatient,

Private Duty Nursing - Home,

Surgical Benefits - Professional (Physician),

Surgical Benefits - Facility,

Mental Health Provider- Inpatient,

Mental Health Provider - Outpatient,

Mental Health Facility - Inpatient,

Mental Health Facility - Outpatient,

Substance Abuse Facility - Inpatient,

Substance Abuse Facility - Outpatient,

Screening X-ray,

Screening laboratory,

Mammogram, High Risk Patient,

Mammogram, Low Risk Patient,

Flu Vaccination,

Eyewear and Eyewear Accessories,

Case Management,

Dermatology,

Durable Medical Equipment,

Diabetic Supplies,

Generic Prescription Drug - Formulary,

Generic Prescription Drug - Non-Formulary,

Allergy,

Intensive Care,

Mental Health,

Neonatol Intensive Care,

Oncology,

Physical Therapy,

Pulmonary,

Renal,

Residential Psychiatric Treatment,

Transitional Care,

Transitional Nursery Care,

Urgent Care,

Unknown

items.benefitsInformation.insuranceTypeCode

enum<string>

Code identifying the type of insurance policy.

Available options:

12,

13,

14,

15,

16,

41,

42,

43,

47,

AP,

C1,

CO,

CP,

D,

DB,

EP,

FF,

GP,

HM,

HN,

HS,

IN,

IP,

LC,

LD,

LI,

LT,

MA,

MB,

MC,

MH,

MI,

MP,

OT,

PE,

PL,

PP,

PR,

PS,

QM,

RP,

SP,

TF,

WC,

WU,

Unknown

items.benefitsInformation.insuranceType

enum<string>

The full name of the insurance type code.

Available options:

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

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

Medicare Secondary, No-fault Insurance including Auto is Primary,

Medicare Secondary Worker's Compensation,

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

Medicare Secondary Black Lung,

Medicare Secondary Veteran's Administration,

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP),

Medicare Secondary, Other Liability Insurance is Primary,

Auto Insurance Policy,

Commercial,

Consolidated Omnibus Budget Reconciliation Act (COBRA),

Medicare Conditionally Primary,

Disability,

Disability Benefits,

Exclusive Provider Organization,

Family or Friends,

Group Policy,

Health Maintenance Organization (HMO),

Health Maintenance Organization (HMO) - Medicare Risk,

Special Low Income Medicare Beneficiary,

Indemnity,

Individual Policy,

Long Term Care,

Long Term Policy,

Life Insurance,

Litigation,

Medicare Part A,

Medicare Part B,

Medicaid,

Medigap Part A,

Medigap Part B,

Medicare Primary,

Other,

Property Insurance - Personal,

Personal,

Personal Payment (Cash - No Insurance),

Preferred Provider Organization (PPO),

Point of Service (POS),

Qualified Medicare Beneficiary,

Property Insurance - Real,

Supplemental Policy,

Tax Equity Fiscal Responsibility Act (TEFRA),

Workers Compensation,

Wrap Up Policy,

Unknown

items.benefitsInformation.planCoverage

string

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

items.benefitsInformation.timeQualifierCode

enum<string>

Code indicating the time period for the benefit information.

Available options:

6,

7,

13,

21,

22,

23,

24,

25,

26,

27,

28,

29,

30,

31,

32,

33,

34,

35,

36,

Unknown

items.benefitsInformation.timeQualifier

enum<string>

The name of the time period qualifier code.

Note that for the patient's deductible, Calendar Year indicates the patient's total deductible amount for the year, while Remaining indicates the amount left to meet the deductible. Visit Payer benefit response to learn more about deductibles.

Available options:

Hour,

Day,

24 Hours,

Years,

Service Year,

Calendar Year,

Year to Date,

Contract,

Episode,

Visit,

Outlier,

Remaining,

Exceeded,

Not Exceeded,

Lifetime,

Lifetime Remaining,

Month,

Week,

Admission,

Unknown

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 responsibility codes.

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 responsibility codes.

items.benefitsInformation.quantityQualifierCode

enum<string>

Code indicating the type of quantity for the benefit.

Available options:

8H,

99,

CA,

CE,

D3,

DB,

DY,

HS,

LA,

LE,

M2,

MN,

P6,

QA,

S7,

S8,

VS,

YY,

Unknown

items.benefitsInformation.quantityQualifier

enum<string>

The name of the quantity qualifier code.

Available options:

Minimum,

Quantity Used,

Covered - Actual,

Covered - Estimated,

Number of Co-insurance Days,

Deductible Blood Units,

Days,

Hours,

Life-time Reserve - Actual,

Life-time Reserve - Estimated,

Maximum,

Month,

Number of Services or Procedures,

Quantity Approved,

Age, High Value,

Age, Low Value,

Visits,

Years,

Unknown

items.benefitsInformation.benefitQuantity

string

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

items.benefitsInformation.authOrCertIndicator

enum<string>

Code indicating whether the benefit is subject to prior authorization or certification.

Available options:

N,

U,

Y

items.benefitsInformation.inPlanNetworkIndicatorCode

enum<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.

Available options:

Y,

N,

U,

W

items.benefitsInformation.inPlanNetworkIndicator

enum<string>

The name of the in-plan network indicator code.

Available options:

Yes,

No,

Unknown,

Not Applicable

items.benefitsInformation.headerLoopIdentifierCode

string

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

items.benefitsInformation.trailerLoopIdentifierCode

string

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

items.benefitsInformation.compositeMedicalProcedureIdentifier

object

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

items.benefitsInformation.benefitsAdditionalInformation

object

Identifying information specific to this type of benefit.

items.benefitsInformation.benefitsAdditionalInformation.planNumber

string

The insurance plan number.

items.benefitsInformation.benefitsAdditionalInformation.policyNumber

string

The patient's policy number.

items.benefitsInformation.benefitsAdditionalInformation.memberId

string

The patient's member ID.

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.

items.benefitsInformation.benefitsAdditionalInformation.groupNumber

string

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

items.benefitsInformation.benefitsAdditionalInformation.groupDescription

string

Group name

items.benefitsInformation.benefitsAdditionalInformation.planDescription

string

Plan name

items.benefitsInformation.benefitsAdditionalInformation.planNetworkDescription

string

Plan network name

items.benefitsInformation.benefitsAdditionalInformation.referralNumber

string

The referral number.

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.

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.

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.

items.benefitsInformation.benefitsAdditionalInformation.drugFormularyNumber

string

The drug formulary number.

items.benefitsInformation.benefitsAdditionalInformation.priorAuthorizationNumber

string

The prior authorization number.

items.benefitsInformation.benefitsAdditionalInformation.insurancePolicyNumber

string

The insurance policy number.

items.benefitsInformation.benefitsAdditionalInformation.medicalAssistanceCategory

string

The medical assistance category.

items.benefitsInformation.benefitsAdditionalInformation.planNetworkIdNumber

string

The plan network identification number.

items.benefitsInformation.benefitsAdditionalInformation.medicaidRecepientIdNumber

string

The Medicaid Recipient Identification number.

items.benefitsInformation.benefitsServiceDelivery

object[]

The delivery or usage pattern for the benefits.

items.benefitsInformation.benefitsServiceDelivery.quantityQualifierCode

enum<string>

Code specifying the type of quantity.

Available options:

DY,

FL,

HS,

MN,

VS,

Unknown

items.benefitsInformation.benefitsServiceDelivery.quantityQualifier

enum<string>

The name of the quantityQualifierCode. For example, Days.

Available options:

Days,

Units,

Hours,

Month,

Visits,

Unknown

items.benefitsInformation.benefitsServiceDelivery.quantity

string

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

items.benefitsInformation.benefitsServiceDelivery.unitForMeasurementCode

enum<string>

This shape is deprecated.

Available options:

Days,

Months,

Visits,

Week,

Years,

Unknown

items.benefitsInformation.benefitsServiceDelivery.unitForMeasurementQualifierCode

enum<string>

Code specifying the unit of measurement for the quantity.

Available options:

DA,

MO,

VS,

WK,

YR,

Unknown

items.benefitsInformation.benefitsServiceDelivery.unitForMeasurementQualifier

enum<string>

The name of the unitForMeasurementQualifierCode. For example, Days.

Available options:

Days,

Months,

Visits,

Week,

Years,

Unknown

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.

items.benefitsInformation.benefitsServiceDelivery.timePeriodQualifierCode

enum<string>

Code specifying the time period for the benefit information.

Available options:

6,

7,

21,

22,

23,

24,

25,

26,

27,

28,

29,

30,

31,

32,

33,

34,

35,

Unknown

items.benefitsInformation.benefitsServiceDelivery.timePeriodQualifier

enum<string>

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

Available options:

Hour,

Day,

Years,

Service Year,

Calendar Year,

Year to Date,

Contract,

Episode,

Visit,

Outlier,

Remaining,

Exceeded,

Not Exceeded,

Lifetime,

Lifetime Remaining,

Month,

Week,

Unknown

items.benefitsInformation.benefitsServiceDelivery.numOfPeriods

string

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

items.benefitsInformation.benefitsServiceDelivery.deliveryOrCalendarPatternCode

enum<string>

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

Available options:

1st Week of the Month,

2nd Week of the Month,

3rd Week of the Month,

4th Week of the Month,

5th Week of the Month,

1st & 3rd Week of the Month,

2nd & 4th Week of the Month,

1st Working Day of Period,

Last Working Day of Period,

Monday through Friday,

Monday through Saturday,

Monday through Sunday,

Monday,

Tuesday,

Wednesday,

Thursday,

Friday,

Saturday,

Sunday,

Monday through Thursday,

Immediately,

As Directed,

Daily Mon. Through Fri.,

1/2 Mon. & 1/2 Tues.,

1/2 Tues. & 1/2 Thurs.,

1/2 Wed. & 1/2 Fri.,

Once Anytime Mon. through Fri.,

Tuesday through Friday,

Monday, Tuesday and Thursday,

Monday, Tuesday and Friday,

Wednesday and Thursday,

Monday, Wednesday and Thursday,

Tuesday, Thursday and Friday,

1/2 Tues. & 1/2 Fri.,

1/2 Mon. & 1/2 Wed.,

1/3 Mon., 1/3 Wed., 1/3 Fri.,

Whenever Necessary,

1/2 By Wed. Bal. By Fri.,

None (Also Used to Cancel or Override a Previous Pattern),

Unknown

items.benefitsInformation.benefitsServiceDelivery.deliveryOrCalendarPatternQualifierCode

enum<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.

Available options:

1,

2,

3,

4,

5,

6,

7,

8,

9,

A,

B,

C,

D,

E,

F,

G,

H,

J,

K,

L,

M,

N,

O,

P,

Q,

R,

S,

SG,

SL,

SP,

SX,

SY,

SZ,

T,

U,

V,

W,

X,

Y,

Unknown

items.benefitsInformation.benefitsServiceDelivery.deliveryOrCalendarPatternQualifier

enum<string>

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

Available options:

1st Week of the Month,

2nd Week of the Month,

3rd Week of the Month,

4th Week of the Month,

5th Week of the Month,

1st & 3rd Week of the Month,

2nd & 4th Week of the Month,

1st Working Day of Period,

Last Working Day of Period,

Monday through Friday,

Monday through Saturday,

Monday through Sunday,

Monday,

Tuesday,

Wednesday,

Thursday,

Friday,

Saturday,

Sunday,

Monday through Thursday,

Immediately,

As Directed,

Daily Mon. Through Fri.,

1/2 Mon. & 1/2 Tues.,

1/2 Tues. & 1/2 Thurs.,

1/2 Wed. & 1/2 Fri.,

Once Anytime Mon. through Fri.,

Tuesday through Friday,

Monday, Tuesday and Thursday,

Monday, Tuesday and Friday,

Wednesday and Thursday,

Monday, Wednesday and Thursday,

Tuesday, Thursday and Friday,

1/2 Tues. & 1/2 Fri.,

1/2 Mon. & 1/2 Wed.,

1/3 Mon., 1/3 Wed., 1/3 Fri.,

Whenever Necessary,

1/2 By Wed. Bal. By Fri.,

None (Also Used to Cancel or Override a Previous Pattern),

Unknown

items.benefitsInformation.benefitsServiceDelivery.deliveryPatternTimeCode

enum<string>

The name of the deliveryPatternTimeCode.

Available options:

1st Shift (Normal Working Hours),

2nd Shift,

3rd Shift,

A.M.,

P.M.,

As Directed,

Any Shift,

None (Also Used to Cancel or Override a Previous Pattern),

Unknown

items.benefitsInformation.benefitsServiceDelivery.deliveryPatternTimeQualifierCode

enum<string>

A code specifying the time for routine shipments or deliveries.

Available options:

A,

B,

C,

D,

E,

F,

G,

Y,

Unknown

items.benefitsInformation.benefitsServiceDelivery.deliveryPatternTimeQualifier

enum<string>

The name of the deliveryPatternTimeCode.

Available options:

1st Shift (Normal Working Hours),

2nd Shift,

3rd Shift,

A.M.,

P.M.,

As Directed,

Any Shift,

None (Also Used to Cancel or Override a Previous Pattern),

Unknown

items.benefitsInformation.additionalInformation

object[]

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

items.benefitsInformation.eligibilityAdditionalInformationList

object[]

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

All other entities associated with the eligibility or benefits.

Identify another entity associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer.

Code identifying an organizational entity, a physical location, property or an individual.

Available options:

Contracted Service Provider,

Preferred Provider Organization (PPO),

Provider,

Third-Party Administrator,

Employer,

Other Physician,

Facility,

Gateway Provider,

Group,

Independent Physicians Association (IPA),

Insured or Subscriber,

Legal Representative,

Origin Carrier,

Primary Care Provider,

Prior Insurance Carrier,

Plan Sponsor,

Payer,

Primary Payer,

Secondary Payer,

Tertiary Payer,

Party Performing Verification,

Vendor,

Organization Completing Configuration Change,

Utilization Management Organization,

Managed Care Organization,

Unknown

The type of entity.

Available options:

Person,

Non-Person Entity

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

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

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

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

Code identifying the type of value provided in entityIdentificationValue. For example, FI - Federal Taxpayer's Identification Number.

Available options:

24,

34,

46,

FA,

FI,

II,

MI,

NI,

PI,

PP,

SV,

XV,

XX,

Unknown

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

Code specifying the relationship between the entity and the patient.

Available options:

01,

02,

27,

41,

48,

65,

72

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 score is high, you must always check the subscriber information to confirm that the coverage is a match for the patient.

errors

object[]

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

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Testing: Send mock requests Insurance Discovery Check Results

curl --request POST \
  --url https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1 \
  --header 'Authorization: <api-key>' \
  --header 'Content-Type: application/json' \
  --data '{
  "provider": {
    "npi": "1234567890"
  },
  "subscriber": {
    "firstName": "John",
    "lastName": "Smith",
    "middleName": "Robert",
    "dateOfBirth": "19800101",
    "ssn": "123456789",
    "gender": "M",
    "address": {
      "address1": "123 Main St",
      "city": "Springfield",
      "state": "IL",
      "postalCode": "62701"
    }
  },
  "encounter": {
    "beginningDateOfService": "20240326",
    "endDateOfService": "20240326"
  }
}'

{
  "discoveryId": "12345678-abcd-4321-efgh-987654321abc",
  "items": [
    {
      "provider": {
        "providerName": "provider",
        "entityType": "Non-Person Entity",
        "npi": "1234567890"
      },
      "subscriber": {
        "memberId": "987654321000",
        "firstName": "John",
        "lastName": "Doe",
        "middleName": "Smith",
        "gender": "M",
        "dateOfBirth": "19900115",
        "groupNumber": "123456-78",
        "planNumber": "123456-EXMPL9876",
        "groupDescription": "Individual On-Exchange",
        "address": {
          "address1": "123 Main Street",
          "city": "ANYTOWN",
          "state": "CA",
          "postalCode": "12345"
        }
      },
      "payer": {
        "name": "EXAMPLE INSURANCE CO"
      },
      "planInformation": {
        "planNumber": "123456-EXMPL9876",
        "groupNumber": "123456-78",
        "groupDescription": "Individual On-Exchange"
      },
      "planDateInformation": {
        "planBegin": "20250101",
        "eligibilityBegin": "20250101",
        "service": "20250301"
      },
      "benefitsInformation": [
        {
          "inPlanNetworkIndicatorCode": "W",
          "benefitsRelatedEntities": [
            {
              "entityIdentifier": "Primary Care Provider",
              "entityIdentification": "XX",
              "entityName": "Dough",
              "entityIdentificationValue": "1234567890",
              "entityFirstname": "Jane",
              "entityType": "Person"
            }
          ],
          "additionalInformation": [
            {
              "description": "To determine if a prior authorization is required, please check the health plan's website."
            }
          ],
          "serviceTypeCodes": [
            "30"
          ],
          "serviceTypes": [
            "Health Benefit Plan Coverage"
          ],
          "inPlanNetworkIndicator": "Not Applicable",
          "name": "Active Coverage",
          "code": "1",
          "planCoverage": "Gold Plan"
        },
        {
          "serviceTypes": [
            "Medical Care"
          ],
          "name": "Active Coverage",
          "planCoverage": "Gold Plan",
          "inPlanNetworkIndicatorCode": "W",
          "serviceTypeCodes": [
            "1"
          ],
          "inPlanNetworkIndicator": "Not Applicable",
          "code": "1"
        },
        {
          "additionalInformation": [
            {
              "description": "Prior authorization may be required. Covered No Limit."
            }
          ],
          "inPlanNetworkIndicatorCode": "Y",
          "code": "1",
          "name": "Active Coverage",
          "serviceTypeCodes": [
            "4"
          ],
          "serviceTypes": [
            "Diagnostic X-Ray"
          ],
          "inPlanNetworkIndicator": "Yes",
          "planCoverage": "Gold Plan"
        },
        {
          "inPlanNetworkIndicator": "Yes",
          "code": "A",
          "serviceTypeCodes": [
            "4"
          ],
          "name": "Co-Insurance",
          "coverageLevel": "Family",
          "serviceTypes": [
            "Diagnostic X-Ray"
          ],
          "inPlanNetworkIndicatorCode": "Y",
          "benefitPercent": "0.5",
          "planCoverage": "Gold Plan",
          "timeQualifierCode": "27",
          "timeQualifier": "Visit",
          "coverageLevelCode": "FAM"
        }
      ],
      "confidence": {
        "score": 0.8,
        "level": "REVIEW_NEEDED",
        "reason": "This record was identified as a low confidence match due to a DOB partial match"
      }
    }
  ],
  "meta": {
    "applicationMode": "production",
    "traceId": "1-abcdef12-123456789abcdef123456789"
  },
  "status": "COMPLETE"
}

Healthcare

EDI platform

Insurance Discovery Check

Enrollment requirements

Response

Retrieve results asynchronously

Authorizations

Body

Response

Healthcare

EDI platform

​Enrollment requirements

​Response

​Retrieve results asynchronously

Authorizations

Body

Response

Enrollment requirements

Response

Retrieve results asynchronously