Overview
An eligibility check is the process of verifying whether a patient has coverage for specific medical benefits under their health insurance plan. This process allows patients and healthcare providers to determine a patient’s financial responsibilities for medical services.
Eligibility checks workflow
Submit eligibility checks to Stedi.
Stedi supports sending X12 270 Eligibility Benefit Inquiry transactions to payers, commonly known as eligibility checks. You can submit requests manually through the Stedi app, or programmatically in either JSON or X12 EDI.
Stedi delivers eligibility checks to the payer.
Stedi routes requests to the payer using the most reliable connection. Stedi receives payer responses in X12 EDI and transforms them into JSON to make them easier to ingest into your business systems.
Receive the payer's benefit response in real time.
Stedi returns the payer’s synchronous X12 271 Eligibility Benefit Response. It contains details about a patient’s medical coverage, including the start and end date of the coverage, covered benefits and services, copayments, deductibles, and out-of-pocket maximums.
X12 HIPAA format
The Health Insurance Portability and Accountability Act (HIPAA) mandates that eligibility checks be submitted in a standardized format: X12 HIPAA. X12 HIPAA is a type of Electronic Data Interchange (EDI), a data format developed in the 1970s to allow businesses to exchange documents electronically.
While some healthcare institutions can submit eligibility checks directly in X12 HIPAA, many of today’s software applications are built to use more modern data formats like JSON. That’s why Stedi offers two types of APIs for eligibility checks: one that accepts JSON and automatically converts it to X12 HIPAA behind the scenes, and another that accepts X12 HIPAA directly.
Was this page helpful?