Eligibility code lists

You may need to reference the following code lists when submitting eligibility checks through the Stedi clearinghouse. Note that this page doesn’t contain every code list in the eligibility request and response; it only contains code lists that are too long to represent clearly within the API reference documentation.

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Delivery or Calendar Pattern Qualifier Codes

Returned in the benefitsInformation.benefitsServiceDelivery.deliveryOrCalendarPatternCode property.

• 1 - 1st Week of the Month
• 2 - 2nd Week of the Month
• 3 - 3rd Week of the Month
• 4 - 4th Week of the Month
• 5 - 5th Week of the Month
• 6 - 1st & 3rd Weeks of the Month
• 7 - 2nd & 4th Weeks of the Month
• 8 - 1st Working Day of Period
• 9 - Last Working Day of Period
• A - Monday through Friday
• B - Monday through Saturday
• C - Monday through Sunday
• D - Monday
• E - Tuesday
• F - Wednesday
• G - Thursday
• H - Friday
• J - Saturday
• K - Sunday
• L - Monday through Thursday
• M - Immediately
• N - As Directed
• O - Daily Mon. through Fri.
• P - 1/2 Mon. & 1/2 Thurs.
• Q - 1/2 Tues. & 1/2 Thurs.
• R - 1/2 Wed. & 1/2 Fri.
• S - Once Anytime Mon. through Fri.
• SG- Tuesday through Friday
• SL - Monday, Tuesday and Thursday
• SP - Monday, Tuesday and Friday
• SX - Wednesday and Thursday
• SY - Monday, Wednesday and Thursday
• SZ - Tuesday, Thursday and Friday
• T - 1/2 Tue. & 1/2 Fri.
• U - 1/2 Mon. & 1/2 Wed.
• V - 1/3 Mon., 1/3 Wed., 1/3 Fri.
• W - Whenever Necessary
• X - 1/2 By Wed., Bal. By Fri.
• Y - None (Also Used to Cancel or Override a Previous Pattern)

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Eligibility and benefit type codes

Returned in the benefitsInformation.code property. Visit Interpret benefit response for a complete list.

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Industry Codes

Used in the benefitsInformation.eligibilityAdditionalInformation.industryCode property when benefitsInformation.eligibilityAdditionalInformationList.codeListQualifierCode is set to ZZ - Mutually defined.

Visit the Centers for Medicare and Medicaid Services Place of Service Code Set for a complete list of codes and descriptions.

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Insurance Type Codes

Returned in the benefitsInformation.insuranceTypeCode property. These codes indicate the type of insurance policy within a specific insurance program.

• 12 - Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
• 13 - Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan
• 14 - Medicare Secondary, No-fault Insurance including Auto is Primary
• 15 - Medicare Secondary Worker’s Compensation
• 16 - Medicare Secondary Public Health Service (PHS) or Other Federal Agency
• 41 - Medicare Secondary Black Lung
• 42 - Medicare Secondary Veteran’s Administration
• 43 - Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
• 47 - Medicare Secondary, Other Liability Insurance is Primary
• AP - Auto Insurance Policy
• C1 - Commercial
• CO - Consolidated Omnibus Budget Reconciliation Act (COBRA)
• CP - Medicare Conditionally Primary
• D - Disability
• DB - Disability Benefits
• EP - Exclusive Provider Organization
• FF - Family or Friends
• GP - Group Policy
• HM - Health Maintenance Organization (HMO)
• HN - Health Maintenance Organization (HMO) - Medicare Risk
• HS - Special Low Income Medicare Beneficiary
• IN - Indemnity
• IP - Individual Policy
• LC - Long Term Care
• LD - Long Term Policy
• LI - Life Insurance
• LT - Litigation
• MA - Medicare Part A
• MB - Medicare Part B
• MC - Medicaid
• MH - Medigap Part A
• MI - Medigap Part B
• MP - Medicare Primary
• OT - Other | When this code is returned by Medicare or a Medicare Part D administrator, it indicates a type of insurance of Medicare Part D.
• PE - Property Insurance - Personal
• PL - Personal
• PP - Personal Payment (Cash - No Insurance)
• PR - Preferred Provider Organization (PPO)
• PS - Point of Service (POS)
• QM - Qualified Medicare Beneficiary
• RP - Property Insurance - Real
• SP - Supplemental Policy
• TF - Tax Equity Fiscal Responsibility Act (TEFRA)
• WC - Workers Compensation
• WU - Wrap Up Policy

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Quantity Qualifier Codes

Returned in the benefitsInformation.quantityQualifierCode property. These codes provide more information about the type of quantity.

• 8H - Minimum
• 99 - Quantity Used
• CA - Covered - Actual
• CE - Covered - Estimated
• D3 - Number of Co-insurance Days
• DB - Deductible Blood Units
• DY - Days
• HS - Hours
• LA - Life-time Reserve - Actual
• LE - Life-time Reserve - Estimated
• M2 - Maximum
• MN - Month
• P6 - Number of Services or Procedures
• QA - Quantity Approved
• S7 - Age, High Value | Use this code when a benefit is based on a maximum age for the patient.
• S8 - Age, Low Value | Use this code when a benefit is based on a minimum age for the patient.
• VS - Visits
• YY - Years

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Time Qualifier Codes

Returned in the benefitsInformation.timeQualifierCode property. These codes provide more information about the time period to which the benefit applies.

• 6 - Hour
• 7 - Day
• 13 - 24 Hours
• 21 - Years
• 22 - Service Year
• 23 - Calendar Year
• 24 - Year to Date
• 25 - Contract
• 26 - Episode
• 27 - Visit
• 28 - Outlier
• 29 - Remaining
• 30 - Exceeded
• 31 - Not Exceeded
• 32 - Lifetime
• 33 - Lifetime Remaining
• 34 - Month
• 35 - Week
• 36 - Admission