Real-Time Eligibility Check (270/271) JSON

This endpoint sends real-time eligibility checks to payers. Visit Check eligibility for a full how-to guide.

• Call this endpoint with a JSON payload.
• Stedi translates your request to the X12 270 EDI format and sends it to the payer.
• The endpoint returns a synchronous response from the payer in both JSON and raw X12 EDI format. The response contains the patient’s eligibility and benefits information.

Real-time eligibility checks are ideal for in-person patient visits, telehealth appointments, and other scenarios where you need immediate information about a patient’s coverage.

We recommend always starting with real-time checks when integrating with a new payer. This approach allows you to quickly test and refine your pipeline through fast feedback loops. Once you’re comfortable with real-time checks, you may also want to start sending asynchronous batch checks to perform periodic refreshes for all or a subset of patients.

Test endpoint

When you submit specific mock requests, Stedi returns mock benefits data from the specified payer you can use for testing. You must use a test Stedi API key for authentication.

Mock requests are free for testing purposes and won’t incur any charges in your Stedi account.

Test eligibility check - CIGNA

Notes:

• encounter: Only service type code 30 is supported.
• provider: You can use any organization name and any NPI, as long as it passes check digit validation. To generate a dummy NPI, you can use this free tool.
• subscriber: You must use the exact values in the test request. Other birthdates, first names, last names, and member IDs return errors.

test request for CIGNA

curl --request POST \
  --url 'https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3' \
  --header 'Authorization: Key {test_api_key}' \
  --header 'Content-Type: application/json' \
  --data '{
    "controlNumber":"123456789",
    "tradingPartnerServiceId": "62308",
    "provider": {
        "organizationName": "Provider Name",
        "npi": "1999999984"
    },
    "subscriber": {
        "firstName": "James",
        "lastName": "Jones",
        "dateOfBirth": "19910202",
        "memberId": "23456789100"
    },
    "encounter": {
        "serviceTypeCodes": ["30"]
    }
}'

Visit Send mock requests for additional mock requests.

Basic eligibility check

The content of your eligibility request depends on your use case and the payer’s requirements. However, a basic eligibility check includes the following information in the request body:

Information	Description
controlNumber	An integer used to identify the transaction. It does not need to be globally unique.
tradingPartnerServiceId	You can find the payer ID in our list of supported payers. If you don’t know the payer, try submitting an insurance discovery check instead.
provider object, name	You must include the provider’s name - either the firstName and lastName of a specific provider within a practice or the organizationName.
provider object, identifier	You must include an identifier. Most often this is the National Provider Identifier (NPI).
subscriber and/or dependents objects	At a minimum, our API requires that you supply at least one of these fields in the request: memberId, dateOfBirth, or lastName. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system. When all four of memberId, dateOfBirth, firstName, and lastName are provided, payers are required to return a response if the member is in their database. Some payers may be able to search with less information, but this varies by payer. We recommend always including the patient’s member ID when possible. Learn more about patient information.
encounter object, service dates	You can specify either a single dateOfService or a beginningDateOfService and endDateOfService. The payer defaults to using the current date in their timezone if you don’t include one. We recommend submitting dates up to 12 months in the past or up to the end of the current month. Dates outside of these ranges are likely to be rejected by many payers, since they may have archived older data and they cannot guarantee eligibility for future months.
encounter object, service or procedure codes	Specify serviceTypeCodes and/or a procedureCode and productOrServiceIDQualifier to request specific types of benefits information. We don’t know which payers support multiple service type codes, so we recommend including no more than one in each request. If you do not include any of these fields, Stedi defaults to using 30 (Plan coverage and general benefits) as the only serviceTypeCodes value. Learn more about checking eligibility for specific services.

MBI lookup for CMS: You must include the patient’s Medicare Beneficiary Identifier (MBI) in every eligibility check to the Centers for Medicare and Medicaid Services (Payer ID: CMS). If the patient doesn’t know their MBI, you can perform an MBI lookup using their Social Security Number instead. Learn more

Character restrictions

Don’t include the following characters in your request data: ~, *, : and ^. They are reserved for delimiters in the resulting X12 EDI transaction, and X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a 400 error if you include these restricted characters in your request.

Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP 400 errors.

Basic character set

The X12 Basic character set includes uppercase letters, digits, space, and some special characters. Lowercase letters and special language characters like ñ are not included.

The following special characters are included:

Extended character set

The Extended character set includes the characters listed in Basic, plus lowercase letters and additional special characters, such as @.

The following additional special characters are included:

Autocorrection

Stedi automatically replaces backticks (`), also known as backquotes or grave accents, with a single quote (') in subscriber and dependents first and last names. This autocorrection prevents errors when submitting your request to payers and intermediary clearinghouses. Stedi returns a message in the response’s warnings array when it makes this replacement.

Conditional requirements

Note that objects marked as required are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.

For example, you must always include the provider object in your request, but you only need to include the dependents object when you need to request benefits information for a dependent on the subscriber’s insurance plan.

Benefit response

Visit Determine patient benefits for detailed explanations and examples of how to use the benefit response to determine the patient’s active coverage, financial responsibility, requirements such as referrals or authorizations, and more.

Network status: The response typically doesn’t confirm whether a particular provider is in- or out-of-network for the patient’s health plan. The most reliable way to confirm network status is by checking with the payer or provider directly. Learn more

Timeout

Insurance payers may take up to 60 seconds to respond to a request, but Stedi holds real-time eligibility check requests open for up to 120 seconds before timing out. During this period, Stedi attempts multiple retries to payers in an effort to complete your request.

Canceling and retrying requests before Stedi’s automatic retry period ends may create multiple ongoing requests to payers and increase your concurrency usage.

Request hedging

When eligibility responses are taking too long, you can use request hedging to try to get results faster. To implement request hedging, send a second request at some internal duration cutoff (for example, 30 seconds) without cancelling the first request. Then, you can use whichever result comes back first. If one of the requests fails, you can wait for the second request to see if it’s successful.

Concurrency limit

Our real-time eligibility check endpoint has rate limiting on a per-account basis. This limit is based on concurrent requests, not requests per second. The default rate limit is 5 concurrent requests; if you need a higher limit, reach out to Support.

Your transactions per second (and thus your concurrency limit) will vary based on the payer response time. If you reach the maximum concurrency limit, Stedi rejects additional requests with a 429 HTTP code until one of your previous requests is completed. Rejected requests have the following error message:

{
  "message": "The request can't be submitted because the sender's submission has been throttled: CUSTOMER_LIMIT",
  "code": "TOO_MANY_REQUESTS",
  "eligibilitySearchId": "019249c7-e176-76b0-a46a-3aef1a519bc4"
}

Asynchronous batch eligibility checks don’t count toward your Stedi account concurrency budget. This allows you to stage thousands of batch requests while continuing to send real-time requests.

Troubleshooting

For a list of possible errors and resolution steps, visit Errors and resolutions.

Authorizations

Authorization

string

header

required

A Stedi API Key for authentication.

Headers

stedi-test

boolean

deprecated

Please create a test API key to submit requests in test mode.

Body

application/json

controlNumber

string

required

An integer to identify the transaction. It doesn't need to be globally unique.

Required string length: 1 - 9

tradingPartnerServiceId

string

required

This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.

Required string length: 1 - 80

subscriber

object

required

The primary policyholder for the insurance plan or a dependent with a unique member ID. If a dependent has a unique member ID, include their information here and leave dependents empty.

• At a minimum, our API requires that you supply at least one of these fields in the request: memberId, dateOfBirth, or lastName. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system.
• When you provide all four of memberId, dateOfBirth, firstName, and lastName, payers are required to return a response if the member is in their database. Some payers may be able to search with less information, but this varies by payer.
• We recommend always including the patient's member ID when possible.
• Enter the patient's name exactly as written on their insurance card, if available, including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces. Visit patient names for all best practices to avoid unnecessary failures.

Show child attributes

subscriber.birthSequenceNumber

string

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

Required string length: 1 - 9

subscriber.caseNumber

string

The case number associated with the subscriber.

Required string length: 1 - 50

subscriber.medicaidRecipientIdentificationNumber

string

The Medicaid Recipient Identification Number. You can provide this number to identify the subscriber when it is the primary number the payer knows a member by (such as for Medicare or Medicaid). Do not supply this value unless it is different from the memberId.

Required string length: 1 - 50

subscriber.spendDownAmount

string

Identify the dollar amount the subscriber will apply toward their spend down amount, if required. For some Medicaid programs, individuals must pay a certain amount towards their healthcare cost (spend down) before coverage starts.

Required string length: 1 - 15

subscriber.spendDownTotalBilledAmount

string

The subscriber's spend down total billed amount.

Required string length: 1 - 15

subscriber.coverageLevelCode

string

This property is no longer used.

subscriber.memberId

string

The member ID for the subscriber's insurance policy.

Required string length: 2 - 80

subscriber.firstName

string

The patient's first name.

Required string length: 1 - 35

subscriber.middleName

string

The patient's middle name or middle initial.

Required string length: 1 - 25

subscriber.lastName

string

The subscriber's last name. Don't include the subscriber's name suffix, such as Jr. or III. Use the designated suffix property instead.

Required string length: 1 - 60

subscriber.suffix

string

The name suffix, such as Jr., Sr., or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

Required string length: 1 - 10

subscriber.gender

enum<string>

Code indicating the subscriber's gender.

Available options:

M,

F

subscriber.dateOfBirth

string

The subscriber's date of birth in YYYYMMDD format.

subscriber.ssn

string

The subscriber's Social Security Number (SSN). Many commercial and government payers ignore this property due to concerns about member privacy. However, some Medicaid programs support alternative searches using the patient's Social Security Number, instead of the member ID.

Required string length: 1 - 11

subscriber.groupNumber

string

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

Required string length: 1 - 50

subscriber.idCard

string

The subscriber's identification card number. Include this property when this number is different than the subscriber's member ID. This is common in Medicaid.

Required string length: 1 - 50

subscriber.providerCode

enum<string>

Use this for providers that are not requesting the eligibility check - the requestor is specified in the provider object. For example, if you are a hospital making an eligibility request, this is where you would specify information about a referring provider's role.

This property is required when the providerIdentifier and referenceIdentificationQualifier properties are populated.

You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SK,

SU

subscriber.referenceIdentificationQualifier

enum<string>

Use this for providers that are not requesting the eligibility check. This is the type of providerIdentifier you are providing.

• Set to HPI when the National Provider ID is mandated for use.
• Set to PXC if you're identifying a type of specialty associated with services provided to the subscriber.

Otherwise, you can set to the following: 9K - Servicer, D3 - National Council for Prescription Drug Programs Pharmacy Number, EI - Employer's Identification Number, HPI - Centers for Medicare and Medicaid Services National Provider Identifier, PXC - Health Care Provider Taxonomy Code, SY - Social Security Number, TJ` - Federal Taxpayer's Identification Number

Available options:

9K,

D3,

EI,

HPI,

PXC,

SY,

TJ

subscriber.providerIdentifier

string

The provider identifier you specified in the referenceIdentificationQualifier property. It is required if you set the referenceIdentificationQualifier. For example, this property could contain the provider's National Provider ID or Federal Taxpayer Identification number.

If you set the referenceIdentificationQualifier to PXC, then this property should contain the provider's taxonomy code.

Required string length: 1 - 50

subscriber.beginningCardIssueDate

string

deprecated

Deprecated; The date the subscriber's identification card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

subscriber.endCardIssueDate

string

deprecated

Deprecated; The date the subscriber's identification card expires, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

subscriber.idCardIssueDate

string

deprecated

Deprecated; The date the subscriber's identification card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

subscriber.planIssueDate

string

deprecated

Deprecated; The date the subscriber's insurance plan was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

subscriber.beginningPlanIssueDate

string

deprecated

Deprecated; The date the subscriber's insurance plan was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

subscriber.endPlanIssueDate

string

deprecated

Deprecated; The date the subscriber's insurance plan ended, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

subscriber.healthCareCodeInformation

object[]

Information about the subscriber's health care diagnosis. You can include up to eight entries in this array.

The first array entry must have diagnosisTypeCode set to ABK. All subsequent entries must have diagnosisTypeCode set to ABF.

Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis

Show child attributes

subscriber.healthCareCodeInformation.diagnosisTypeCode

enum<string>

required

The type of diagnosis code you are providing. You can set to BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, BF- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, or ABF- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis.

Note that ICD-9 codes are deprecated and should no longer be used in eligibility checks.

Available options:

BK,

ABK,

BF,

ABF

subscriber.healthCareCodeInformation.diagnosisCode

string

required

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

Required string length: 1 - 30

subscriber.address

object

The subscriber's address. You must include at least the address1 and city properties in this object.

Show child attributes

subscriber.address.address1

string

required

The first line of the address.

Required string length: 1 - 55

subscriber.address.city

string

required

The city.

Required string length: 2 - 30

subscriber.address.address2

string

The second line of the address.

Required string length: 1 - 55

subscriber.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

subscriber.address.postalCode

string

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

Required string length: 5 - 9

subscriber.address.countryCode

string

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

Required string length: 2

subscriber.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

subscriber.additionalIdentification

object

Use this object when you need to provide an identification number other than or in addition to the member ID. For example, you may provide the patient account number. Don't include the health insurance claim number or the medicaid recipient ID number here unless they are different from the member ID.

Show child attributes

subscriber.additionalIdentification.planNumber

string

The insurance plan number.

Required string length: 1 - 50

subscriber.additionalIdentification.policyNumber

string

The insurance group or policy number.

Required string length: 1 - 50

subscriber.additionalIdentification.memberIdentificationNumber

string

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

Required string length: 1 - 50

subscriber.additionalIdentification.contractNumber

string

The contract number for an existing contract between the payer and the provider requesting the eligibility check.

Required string length: 1 - 50

subscriber.additionalIdentification.medicalRecordIdentificationNumber

string

The medical record identification number.

Required string length: 1 - 50

subscriber.additionalIdentification.patientAccountNumber

string

The patient account number.

Required string length: 1 - 50

subscriber.additionalIdentification.healthInsuranceClaimNumber

string

The health insurance claim number.

Required string length: 1 - 50

subscriber.additionalIdentification.identificationCardSerialNumber

string

The identification card serial number. You can include this when the ID card has a number in addition to the member ID number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member, such as a replacement card.

Required string length: 1 - 50

subscriber.additionalIdentification.insurancePolicyNumber

string

The insurance policy number.

Required string length: 1 - 50

subscriber.additionalIdentification.planNetworkIdentificationNumber

string

The plan network identification number.

Required string length: 1 - 50

subscriber.additionalIdentification.agencyClaimNumber

string

The Property and Casualty Claim Number associated with the patient. You should only submit this value when when you are submitting an eligibility request to a property and casualty payer.

Required string length: 1 - 50

provider

object

required

Information about the entity requesting the eligibility check. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider.

• You must provide the organizationName (if the entity is an organization), or firstName and lastName (if the provider is an individual).
• You must also provide an identifier - this is typically the provider's National Provider Identifier (npi). If the provider doesn't have an NPI, you can supply their taxId or ssn.
• You shouldn't include additional properties, such as taxId or address, unless they are specifically required or suggested by the payer.

Show child attributes

provider.organizationName

string

The provider's business name. This property is required if the provider is not a person.

Required string length: 1 - 60

provider.firstName

string

The provider's first name. This property is required if the provider is an individual.

Required string length: 1 - 35

provider.lastName

string

The provider's last name. This property is required if the provider is an individual.

Required string length: 1 - 60

provider.npi

string

The provider's National Provider Identifier (NPI). This identifier is required for all healthcare providers who are eligible to receive an NPI. Some non-traditional providers such as transportation services, durable medical equipment (DME) suppliers, or alternative medicine practitioners are not eligible to receive an NPI. If the provider doesn't have an NPI, you can supply either their taxId or ssn.

Required string length: 2 - 80

provider.serviceProviderNumber

string

The provider's service provider number. Only include when the provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.

Required string length: 2 - 80

provider.payorId

string

Only used for payer-to-payer transactions, which are not currently supported. Do not use.

Required string length: 2 - 80

provider.taxId

string

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

Required string length: 2 - 80

provider.ssn

string

The provider's Social Security Number (SSN). - Only include when the provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service. - Don't use this for Federally-administered programs, such as Medicare.

Required string length: 2 - 80

provider.pharmacyProcessorNumber

string

The provider's pharmacy processor number. Only include when the provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.

Required string length: 2 - 80

provider.servicesPlanID

string

deprecated

This shape is deprecated.

Required string length: 2 - 80

provider.employersId

string

deprecated

Deprecated; The submitter's Employer's Identification Number (EIN). Only use when an employer is checking the eligibility and benefits of their employees. This shape is deprecated: This property is no longer used.

Required string length: 2 - 80

provider.providerCode

enum<string>

Communicate the provider's role in the type of benefits specified in the request.

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SB,

SK,

SU,

Unknown

provider.referenceIdentification

string

The provider's Taxonomy Code. Only used when the provider's taxonomy code is relevant to the eligibility/benefit inquiry. For example, an institutional provider such as a hospital may need to use a taxonomy code to specify a specific unit or department.

provider.providerType

enum<string>

Identify the type of provider.

Available options:

payer,

third-party administrator,

employer,

hospital,

facility,

gateway provider,

plan sponsor,

provider

provider.stateLicenceNumber

string

The provider's state license number. If you include this information, you must also include the informationReceiverAdditionalIdentifierState.

Required string length: 1 - 50

provider.medicareProviderNumber

string

The provider's Medicare provider number.

Required string length: 1 - 50

provider.medicaidProviderNumber

string

The provider's Medicaid provider number.

Required string length: 1 - 50

provider.facilityIdNumber

string

The ID number for the provider's facility.

Required string length: 1 - 50

provider.contractNumber

string

The provider's contract number.

Required string length: 1 - 50

provider.contactNumber

string

deprecated

The provider's contract number. This shape is deprecated: Use contractNumber instead.

Required string length: 1 - 50

provider.devicePinNumber

string

The provider's electronic device pin number.

Required string length: 1 - 50

provider.submitterIdNumber

string

The provider's submitter identification number.

Required string length: 1 - 50

provider.providerPlanNetworkIdNumber

string

The provider's plan network identification number.

Required string length: 1 - 50

provider.facilityNetworkIdNumber

string

The provider's facility network identification number.

Required string length: 1 - 50

provider.priorIdentifierNumber

string

The provider's prior identifier number.

Required string length: 1 - 50

provider.informationReceiverAdditionalIdentifierState

string

The two-character state ID of the state that assigned the stateLicenseNumber.

Required string length: 1 - 80

provider.address

object

The address of the provider requesting the information. This is required when the provider has multiple locations and you need to identify the specific location making the request. You must include at least the address1 and city properties in this object.

Show child attributes

provider.address.address1

string

required

The first line of the address.

Required string length: 1 - 55

provider.address.city

string

required

The city.

Required string length: 2 - 30

provider.address.address2

string

The second line of the address.

Required string length: 1 - 55

provider.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

provider.address.postalCode

string

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

Required string length: 5 - 9

provider.address.countryCode

string

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

Required string length: 2

provider.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

submitterTransactionIdentifier

string

This property is only relevant for asynchronous batch eligibility checks.

tradingPartnerName

string

The payer's name, such as Cigna or Aetna.

Required string length: 1 - 80

portalUsername

string

The username that the provider uses to log in to the payer's portal. This is not commonly used.

Required string length: 1 - 50

portalPassword

string

The password that the provider uses to log in to the payer's portal. This is not commonly used.

Required string length: 1 - 50

encounter

object

Details about the eligibility or benefit information you are requesting for the patient.

• If you don't specify a service date (either a single day or a range of dates), the payer defaults to using the current date in their timezone.
• If you don't specify either serviceTypeCodes or a procedureCode and productOrServiceIDQualifier, Stedi defaults to using 30 (Plan coverage and general benefits) as the only serviceTypeCodes value.
• We recommend submitting dates up to 12 months in the past or up to the end of the current month. Dates outside of these ranges are likely to be rejected by many payers, since they may have archived older data and they cannot guarantee eligibility for future months.
• Payers can have different rules for future dates of service - for example, some payers may only return benefits information for dates up to the end of the current calendar month, but others may support dates further into the future.

Show child attributes

encounter.beginningDateOfService

string

The beginning date of service, formatted as YYYYMMDD. If you include this value, you must also include the endDateOfService.

encounter.endDateOfService

string

The end date of service, formatted as YYYYMMDD. If you include this value, you must also include the beginningDateOfService.

encounter.dateOfService

string

The date of service, formatted as YYYYMMDD. You can use this value to specify a single occasion, such as a doctor's visit. If you don't specify a service date (either a single day or a range of dates), the payer defaults to using the current date in their timezone.

encounter.serviceTypeCodes

enum<string>[]

One or more codes classifying the type of services for which you want to receive benefits information.

If you do not specify a service type code or a procedureCode and productOrServiceIDQualifier, Stedi defaults to using 30 - Health Benefit Plan Coverage. Visit Service Type Codes for a complete list.

Note that not all payers support all service type codes, and not all payers support multiple service type codes in the same request. We recommend including one service type code per request unless you're sure the payer supports multiple.

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

encounter.priorAuthorizationOrReferralNumber

string

The prior authorization or referral number for a particular benefit or procedure.

encounter.referenceIdentificationQualifier

enum<string>

The type of information you provided in the priorAuthorizationOrReferralNumber property. You can set this to 9F - Referral Number or G1 - Prior Authorization Number.

Available options:

9F,

G1

encounter.industryCode

enum<string>

The type of facility where the service was provided. You can set this to one of the place of service codes.

Available options:

01,

02,

03,

04,

05,

06,

07,

08,

09,

10,

11,

12,

13,

14,

15,

16,

17,

18,

19,

20,

21,

22,

23,

24,

25,

26,

31,

32,

33,

34,

41,

42,

49,

50,

51,

52,

53,

54,

55,

56,

57,

58,

60,

61,

62,

65,

71,

72,

81,

99

encounter.productOrServiceIDQualifier

enum<string>

Code identifying the type/source of the procedureCode. You can set this to AD - American Dental Association Codes, 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.

Available options:

AD,

CJ,

HC,

ID,

IV,

N4,

ZZ

encounter.procedureCode

string

The procedure code.

Required string length: 1 - 48

encounter.procedureModifiers

string[]

The procedure modifier that provides additional information related to the performance of the service.

encounter.diagnosisCodePointer

string[]

Diagnosis code pointers in order of importance to the service. These pointers are an index to the ICD-10 codes you included in the subscriber.healthCareCodeInformation or dependents.healthCareCodeInformation object arrays. The pointer values can be from 1 - 8 (integer numbers). If you are including diagnosis codes, you must set at least one pointer here for the primary diagnosis. Then, you can add up to three additional pointers (up to four in total). Don't put ICD-10 codes here.

encounter.medicalProcedures

object[]

Use only when you need to send multiple procedure codes in a single request. Otherwise, use the encounter.procedureCode and encounter.productOrServiceIDQualifier properties.

Show child attributes

encounter.medicalProcedures.productOrServiceIDQualifier

enum<string>

required

Code identifying the type/source of the procedureCode. You can set this to AD - American Dental Association Codes, 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.

Available options:

AD,

CJ,

HC,

ID,

IV,

N4,

ZZ

encounter.medicalProcedures.procedureCode

string

required

The procedure code.

Required string length: 1 - 48

encounter.medicalProcedures.procedureModifiers

string[]

Procedure modifiers that provide additional information related to the service.

encounter.medicalProcedures.diagnosisCodePointer

string[]

The diagnosis code pointer.

externalPatientId

string

A unique identifier for the patient that Stedi uses to identify and correlate historical eligibility checks for the same individual. We recommend including this value in all requests.

Maximum length: 36

eligibilitySearchId

string

The unique identifier for the eligibility search being edited and 'retried'.

informationReceiverName

object

deprecated

Use the corresponding properties in the provider object instead. This shape is deprecated.

Show child attributes

informationReceiverName.stateLicenceNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.medicareProviderNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.medicaidProviderNumber

string

The provider's Medicaid provider number.

Required string length: 1 - 50

informationReceiverName.facilityIdNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.contractNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.contactNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.devicePinNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.submitterIdNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.nationalProviderIdentifier

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.providerPlanNetworkIdNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.facilityNetworkIdNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.priorIdentifierNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.socialSecurityNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.federalTaxpayerIdentificationNumber

string

deprecated

This shape is deprecated.

Required string length: 1 - 50

informationReceiverName.informationReceiverAdditionalIdentifierState

string

deprecated

This shape is deprecated.

Required string length: 1 - 80

informationReceiverName.address

object

This shape is deprecated.

Show child attributes

informationReceiverName.address.address1

string

required

The first line of the address.

Required string length: 1 - 55

informationReceiverName.address.city

string

required

The city.

Required string length: 2 - 30

informationReceiverName.address.address2

string

The second line of the address.

Required string length: 1 - 55

informationReceiverName.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

informationReceiverName.address.postalCode

string

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

Required string length: 5 - 9

informationReceiverName.address.countryCode

string

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

Required string length: 2

informationReceiverName.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

dependents

object[]

A dependent for which you want to retrieve benefits information.

• You can only submit one dependent per eligibility check.
• An individual qualifies as a dependent for eligibility checks when they are listed as a dependent on the subscriber's insurance plan AND the payer cannot uniquely identify them through information outside the subscriber's policy. For example, if the dependent has their own member ID number, you should identify them in the subscriber object instead.
• Each payer has different requirements, so you should supply the fields necessary for each payer to identify the dependent in their system. However, we strongly recommend including the dependent's date of birth in the request when available because many payers return errors without it.
• Enter the patient's name exactly as written on their insurance card, if available, including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces. Visit patient names for all best practices to avoid unnecessary failures.

Show child attributes

dependents.birthSequenceNumber

string

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

Required string length: 1 - 9

dependents.individualRelationshipCode

enum<string>

The dependent's relationship to the subscriber. You can set this to 01 - Spouse, 19 - Child, 34 - Other Adult.

Available options:

01,

19,

34

dependents.issueNumber

string

The issue number for the dependent's insurance policy.

Required string length: 1 - 50

dependents.eligibilityCategory

string

The eligibility category for the dependent.

Required string length: 1 - 50

dependents.memberId

string

Only use for property and casualty use cases when the property and casualty patient identifier is a member ID and would be used in an 837 healthcare claim submission.

Required string length: 2 - 80

dependents.firstName

string

The dependent's first name.

Required string length: 1 - 35

dependents.middleName

string

The dependent's middle name or middle initial.

Required string length: 1 - 25

dependents.lastName

string

The dependent's last name. Don't include the dependent's name suffix, such as Jr. or III. Use the designated suffix property instead.

Required string length: 1 - 60

dependents.suffix

string

The dependent's name suffix, such as Sr. or III. Only include the dependent's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

Required string length: 1 - 10

dependents.gender

enum<string>

Code indicating the dependent's gender.

Available options:

M,

F

dependents.dateOfBirth

string

The dependent's date of birth (DOB) in YYYYMMDD format. We strongly recommend including the DOB in your request. Many payers need this information to identify the patient in their system and will immediately return an error when it's not provided.

dependents.ssn

string

The dependent's social security number. Don't use this for Federally-administered programs, such as Medicare.

Required string length: 1 - 11

dependents.groupNumber

string

The group number for the dependent's insurance plan.

Required string length: 1 - 50

dependents.idCard

string

The dependent's insurance card number.

Required string length: 1 - 50

dependents.providerCode

enum<string>

Use this for providers that are not requesting the eligibility check - the requestor is specified in the provider object. For example, if you are a hospital making an eligibility request, this is where you would specify information about a referring provider's role.

You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE- Performing, R- Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SK,

SU

dependents.referenceIdentificationQualifier

enum<string>

The type of providerIdentifier you are using. Use for providers that are not requesting the eligibility check, such as the referring provider.

• Set to HPI when the National Provider ID is mandated for use.
• Set to PXC if you're identifying a type of specialty associated with services provided to the dependent.

Otherwise, you can set to the following: 9K - Servicer, D3 - National Council for Prescription Drug Programs Pharmacy Number, EI - Employer's Identification Number, HPI - Centers for Medicare and Medicaid Services National Provider Identifier, PXC - Health Care Provider Taxonomy Code, SY - Social Security Number, TJ - Federal Taxpayer's Identification Number

Available options:

9K,

D3,

EI,

HPI,

PXC,

SY,

TJ

dependents.providerIdentifier

string

The provider identifier you specified in the referenceIdentificationQualifier property. For example, the provider's National Provider ID or Federal Taxpayer Identification number. If you set the referenceIdentificationQualifier to PXC, then this property should contain the provider's taxonomy code.

Required string length: 1 - 50

dependents.beginningCardIssueDate

string

deprecated

Deprecated; The date the insurance card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

dependents.endCardIssueDate

string

deprecated

Deprecated; The date the insurance card expires, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

dependents.idCardIssueDate

string

deprecated

Deprecated; The date the identification card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

dependents.planIssueDate

string

deprecated

Deprecated; The date the insurance plan was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

dependents.beginningPlanIssueDate

string

deprecated

Deprecated; The date the insurance plan begins, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

dependents.endPlanIssueDate

string

deprecated

Deprecated; The date the insurance plan ends, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.

dependents.healthCareCodeInformation

object[]

Information about the dependent's health care diagnosis. You can include up to eight entries in this array.

The first array entry must have diagnosisTypeCode set to ABK. All subsequent entries must have diagnosisTypeCode set to ABF.

Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis

Show child attributes

dependents.healthCareCodeInformation.diagnosisTypeCode

enum<string>

required

The type of diagnosis code you are providing. You can set to BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, BF- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, or ABF- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis.

Note that ICD-9 codes are deprecated and should no longer be used in eligibility checks.

Available options:

BK,

ABK,

BF,

ABF

dependents.healthCareCodeInformation.diagnosisCode

string

required

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

Required string length: 1 - 30

dependents.address

object

The dependent's address. You must include at least the address1 and city properties in this object.

Show child attributes

dependents.address.address1

string

required

The first line of the address.

Required string length: 1 - 55

dependents.address.city

string

required

The city.

Required string length: 2 - 30

dependents.address.address2

string

The second line of the address.

Required string length: 1 - 55

dependents.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

dependents.address.postalCode

string

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

Required string length: 5 - 9

dependents.address.countryCode

string

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

Required string length: 2

dependents.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

dependents.additionalIdentification

object

Use this object when you need to provide an identification number other than or in addition to the member ID. For example, you may provide the patient account number. Don't include the health insurance claim number or the medicaid recipient ID number here unless they are different from the member ID.

Show child attributes

dependents.additionalIdentification.planNumber

string

The insurance plan number.

Required string length: 1 - 50

dependents.additionalIdentification.policyNumber

string

The insurance group or policy number.

Required string length: 1 - 50

dependents.additionalIdentification.memberIdentificationNumber

string

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

Required string length: 1 - 50

dependents.additionalIdentification.contractNumber

string

The contract number for an existing contract between the payer and the provider requesting the eligibility check.

Required string length: 1 - 50

dependents.additionalIdentification.medicalRecordIdentificationNumber

string

The medical record identification number.

Required string length: 1 - 50

dependents.additionalIdentification.patientAccountNumber

string

The patient account number.

Required string length: 1 - 50

dependents.additionalIdentification.healthInsuranceClaimNumber

string

The health insurance claim number.

Required string length: 1 - 50

dependents.additionalIdentification.identificationCardSerialNumber

string

The identification card serial number. You can include this when the ID card has a number in addition to the member ID number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member, such as a replacement card.

Required string length: 1 - 50

dependents.additionalIdentification.insurancePolicyNumber

string

The insurance policy number.

Required string length: 1 - 50

dependents.additionalIdentification.planNetworkIdentificationNumber

string

The plan network identification number.

Required string length: 1 - 50

dependents.additionalIdentification.agencyClaimNumber

string

The Property and Casualty Claim Number associated with the patient. You should only submit this value when when you are submitting an eligibility request to a property and casualty payer.

Required string length: 1 - 50

Response

200

application/json

EligibilityCheck 200 response

meta

object

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

Show child attributes

meta.senderId

string

The sender ID Stedi assigns to this request.

meta.submitterId

string

The submitter ID Stedi assigns to this request.

meta.billerId

string

The biller ID Stedi assigns to this request.

meta.applicationMode

enum<string>

The type of data in the request. This is either production when you send a request with a standard API key or test when you send a request in test mode with a test API key. The information value is not currently used.

Available options:

production,

test,

information

meta.traceId

string

The unique ID Stedi assigns to this request.

meta.outboundTraceId

string

The unique ID Stedi assigns to this request.

controlNumber

string

An identifier for the payer's response.

reassociationKey

string

Deprecated; do not use.

tradingPartnerServiceId

string

An ID for the payer you identified in the original eligibility check request. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.

provider

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.

Show child attributes

provider.providerName

string

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

provider.providerFirstName

string

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

provider.providerOrgName

string

The provider's organization name.

provider.middleName

string

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

provider.suffix

string

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

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

provider.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

provider.npi

string

The provider's National Provider Identifier (NPI).

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

provider.referenceIdentification

string

The Health Care Provider Taxonomy Code.

provider.ssn

string

The Social Security Number (SSN).

provider.federalTaxpayersIdNumber

string

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

provider.payorIdentification

string

The Payor Identification.

provider.pharmacyProcessorNumber

string

The pharmacy processor number.

provider.serviceProviderNumber

string

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

provider.servicesPlanID

string

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

provider.address

object

The provider's contact information.

Show child attributes

provider.address.address1

string

The first line of the address.

Required string length: 1 - 55

provider.address.address2

string

The second line of the address.

Required string length: 1 - 55

provider.address.city

string

The city.

Required string length: 2 - 30

provider.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

provider.address.postalCode

string

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

Required string length: 5 - 9

provider.address.countryCode

string

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

Required string length: 2

provider.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

provider.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.

provider.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

Show child attributes

provider.aaaErrors.field

string

The error type, AAA.

provider.aaaErrors.description

string

The error description.

provider.aaaErrors.location

string

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

provider.aaaErrors.possibleResolutions

string

Information to help you correct the error.

provider.aaaErrors.code

enum<string>

The error code.

Available options:

15,

41,

43,

44,

45,

46,

47,

48,

50,

51,

79,

97,

T4

provider.aaaErrors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

subscriber

object

Information about the primary policyholder for the insurance plan listed in the original eligibility check request. The response will always include either the subscriber's name or member ID for identification, but most payers will also return the subscriber's date of birth and other identifying information.

Show child attributes

subscriber.healthCareDiagnosisCodes

object[]

Information about the patient's healthcare diagnosis.

Show child attributes

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.

subscriber.healthCareDiagnosisCodes.diagnosisCode

string

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

subscriber.memberId

string

The member ID for the subscriber's insurance policy.

subscriber.firstName

string

The subscriber's first name.

subscriber.lastName

string

The subscriber's last name.

subscriber.middleName

string

The subscriber's middle name or initial.

subscriber.suffix

string

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

subscriber.gender

enum<string>

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

Available options:

M,

F,

U

subscriber.entityIdentifier

enum<string>

The entity identifier for the subscriber.

Available options:

Insured or Subscriber

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

subscriber.uniqueHealthIdentifier

string

The subscriber's unique health identifier.

subscriber.dateOfBirth

string

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

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

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

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

subscriber.description

string

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

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

subscriber.dateTimePeriodFormatQualifier

enum<string>

The format of the military service date and time period.

Available options:

D8,

RD8

subscriber.dateTimePeriod

string

The military service date, formatted as YYYYMMDD.

subscriber.startDateTimePeriod

string

The military service start date, formatted as YYYYMMDD.

subscriber.endDateTimePeriod

string

The military service end date, formatted as YYYYMMDD.

subscriber.ssn

string

The subscriber's Social Security Number (SSN).

subscriber.groupNumber

string

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

subscriber.planNumber

string

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

subscriber.planNetworkIdNumber

string

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

subscriber.groupDescription

string

Group name

subscriber.planDescription

string

Plan name

subscriber.planNetworkDescription

string

Plan network name

subscriber.relationToSubscriber

enum<string>

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

Available options:

Self

subscriber.relationToSubscriberCode

enum<string>

For the subscriber, this is always 18 for Self.

Available options:

18

subscriber.insuredIndicator

enum<string>

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

Available options:

Y

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

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

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.

subscriber.address

object

Show child attributes

subscriber.address.address1

string

The first line of the address.

Required string length: 1 - 55

subscriber.address.address2

string

The second line of the address.

Required string length: 1 - 55

subscriber.address.city

string

The city.

Required string length: 2 - 30

subscriber.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

subscriber.address.postalCode

string

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

Required string length: 5 - 9

subscriber.address.countryCode

string

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

Required string length: 2

subscriber.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

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.

Show child attributes

subscriber.responseProvider.providerName

string

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

subscriber.responseProvider.providerFirstName

string

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

subscriber.responseProvider.providerOrgName

string

The provider's organization name.

subscriber.responseProvider.middleName

string

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

subscriber.responseProvider.suffix

string

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

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

subscriber.responseProvider.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

subscriber.responseProvider.npi

string

The provider's National Provider Identifier (NPI).

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

subscriber.responseProvider.referenceIdentification

string

The Health Care Provider Taxonomy Code.

subscriber.responseProvider.ssn

string

The Social Security Number (SSN).

subscriber.responseProvider.federalTaxpayersIdNumber

string

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

subscriber.responseProvider.payorIdentification

string

The Payor Identification.

subscriber.responseProvider.pharmacyProcessorNumber

string

The pharmacy processor number.

subscriber.responseProvider.serviceProviderNumber

string

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

subscriber.responseProvider.servicesPlanID

string

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

subscriber.responseProvider.address

object

The provider's contact information.

Show child attributes

subscriber.responseProvider.address.address1

string

The first line of the address.

Required string length: 1 - 55

subscriber.responseProvider.address.address2

string

The second line of the address.

Required string length: 1 - 55

subscriber.responseProvider.address.city

string

The city.

Required string length: 2 - 30

subscriber.responseProvider.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

subscriber.responseProvider.address.postalCode

string

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

Required string length: 5 - 9

subscriber.responseProvider.address.countryCode

string

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

Required string length: 2

subscriber.responseProvider.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

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.

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

Show child attributes

subscriber.responseProvider.aaaErrors.field

string

The error type, AAA.

subscriber.responseProvider.aaaErrors.description

string

The error description.

subscriber.responseProvider.aaaErrors.location

string

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

subscriber.responseProvider.aaaErrors.possibleResolutions

string

Information to help you correct the error.

subscriber.responseProvider.aaaErrors.code

enum<string>

The error code.

Available options:

15,

41,

43,

44,

45,

46,

47,

48,

50,

51,

79,

97,

T4

subscriber.responseProvider.aaaErrors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

subscriber.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 subscriber or dependent level include missing or incorrect identifying information and that the payer was unable to locate the patient in their system. Learn more

Show child attributes

subscriber.aaaErrors.field

string

The error type, AAA.

subscriber.aaaErrors.description

string

The error description.

subscriber.aaaErrors.location

string

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

subscriber.aaaErrors.possibleResolutions

string

Information to help you correct the error.

subscriber.aaaErrors.code

enum<string>

The error code.

Available options:

15,

33,

35,

42,

43,

45,

47,

48,

49,

51,

52,

53,

54,

55,

56,

57,

58,

60,

61,

62,

63,

69,

70,

71,

72,

73,

74,

75,

76,

78,

98,

AA,

AE,

AF,

AG,

AO,

CI,

E8,

IA,

MA

subscriber.aaaErrors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

subscriberTraceNumbers

object[]

A unique identifier the payer may assign to the transaction. Note that Stedi doesn't support setting a subscriber trace number in the eligibility check request because there is no need to include a trace number for real-time queries.

Show child attributes

subscriberTraceNumbers.traceTypeCode

string

The code that identifies the type of trace number. Can be 1 - Current Transaction Trace Numbers (refers to trace numbers assigned by the payer) or 2 - Referenced Trace Numbers (refers to numbers sent in the original eligibility check request).

subscriberTraceNumbers.traceType

string

The full name of the traceTypeCode. For example Current Transaction Trace Numbers.

subscriberTraceNumbers.referenceIdentification

string

The unique trace number assigned to the transaction.

subscriberTraceNumbers.originatingCompanyIdentifier

string

The identifier of the organization that assigned the trace number.

subscriberTraceNumbers.secondaryReferenceIdentification

string

Identifies a subdivision within the organization that assigned the trace number.

payer

object

Information about the payer providing the benefits information. The response will always include the payer's business name and an identifier, such as the payer's tax ID. Most payers also include contact information.

Show child attributes

payer.entityIdentifier

enum<string>

The entity identifier code for the payer.

Available options:

Third-Party Administrator,

Employer,

Gateway Provider,

Plan Sponsor,

Payer

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

payer.firstName

string

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

payer.lastName

string

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

payer.name

string

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

payer.middleName

string

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

payer.suffix

string

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

payer.federalTaxpayersIdNumber

string

The payer's federal taxpayer's identification number.

payer.naic

string

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

payer.npi

string

The payer's National Provider Identifier (NPI).

payer.centersForMedicareAndMedicaidPlanId

string

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

payer.payorIdentification

string

The payor identification.

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.

Show child attributes

payer.contactInformation.name

string

The name of the contact person.

payer.contactInformation.contacts

object[]

The contact information.

Contacts

Show child attributes

payer.contactInformation.contacts.communicationMode

string

The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).

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.

payer.etin

string

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

payer.employersId

string

deprecated

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

payer.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 payer level include issues with payer enrollment and that the payer's system is down or experiencing issues. Learn more

Show child attributes

payer.aaaErrors.field

string

The error type, AAA.

payer.aaaErrors.description

string

The error description.

payer.aaaErrors.location

string

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

payer.aaaErrors.possibleResolutions

string

Information to help you correct the error.

payer.aaaErrors.code

enum<string>

The error code.

Available options:

04,

41,

42,

79,

80,

T4

payer.aaaErrors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Resubmission allowed,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

planInformation

object

Additional identification for the subscriber's healthcare plan.

Show child attributes

planInformation.stateLicenseNumber

string

The state license number

planInformation.medicareProviderNumber

string

The Medicare provider number

planInformation.medicaidProviderNumber

string

The Medicaid provider number

planInformation.facilityIdNumber

string

The facility ID number

planInformation.personalIdentificationNumber

string

The personal identification number (PIN)

planInformation.planNumber

string

The plan number

planInformation.planDescription

string

The plan description

planInformation.policyNumber

string

The group or policy number

planInformation.memberId

string

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

planInformation.caseNumber

string

The case number

planInformation.familyUnitNumber

string

The family unit number

planInformation.groupNumber

string

The group number

planInformation.groupDescription

string

The group description

planInformation.referralNumber

string

The referral number

planInformation.alternativeListId

string

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

planInformation.classOfContractCode

string

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

planInformation.coverageListId

string

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

planInformation.contractNumber

string

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

planInformation.medicalRecordIdentificationNumber

string

The medical record identification number

planInformation.electronicDevicePin

string

The electronic device pin number

planInformation.submitterIdentificationNumber

string

The submitter identification number

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.

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.

planInformation.drugFormularyNumber

string

The drug formulary number

planInformation.priorAuthorizationNumber

string

The prior authorization number

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.

planInformation.idCardNumber

string

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

planInformation.centersForMedicareAndMedicaidServicesNPI

string

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

planInformation.issueNumber

string

The issue number

planInformation.insurancePolicyNumber

string

The insurance policy number

planInformation.userIdentification

string

The user identification

planInformation.medicalAssistanceCategory

string

The medical assistance category

planInformation.eligibilityCategory

string

The eligibility category

planInformation.planNetworkIdNumber

string

The plan network identification number

planInformation.planNetworkIdDescription

string

The plan, group, or plan network name

planInformation.facilityNetworkIdentificationNumber

string

The facility network identification number

planInformation.medicaidRecipientIdNumber

string

The Medicaid recipient identification number

planInformation.priorIdNumber

string

The prior identifier number

planInformation.socialSecurityNumber

string

The social security number

planInformation.federalTaxpayersIdentificationNumber

string

The federal taxpayer's identification number

planInformation.agencyClaimNumber

string

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

planDateInformation

object

Contains the dates associated with the subscriber and dependents' (if applicable) insurance plan. This information is used to determine their eligibility for benefits.

• Date formats:
  • Single dates are formatted as YYYYMMDD
  • Date ranges are formatted as YYYYMMDD-YYYYMMDD
• Most fields contain a single date, but some can contain either a single date or a date range. Each field's documentation specifies its format.
• Fields that can contain either a single date or date range include: plan, eligibility, planBegin, admission, and service.
• The provided dates apply to every benefit within the patient's health plan unless specifically noted within a benefitsInformation.benefitsDateInformation object.
• If the payer sends back date(s) that are different for the subscriber and dependents, Stedi includes only the dates for the dependent in this object and omits the subscriber's date(s). Dependents can have different coverage dates than the subscriber due to qualifying life events, such as starting a new job or passing the age limit for coverage through their parent's plan.
• Most payers return either plan or planBegin and planEnd, but the exact dates returned depend on the payer's discretion and the patient's insurance 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.

Show child attributes

planDateInformation.discharge

string

The discharge date. Single date (YYYYMMDD).

planDateInformation.issue

string

The issue date. Single date (YYYYMMDD).

planDateInformation.effectiveDateOfChange

string

The effective date of change. Single date (YYYYMMDD).

planDateInformation.plan

string

Plan effective dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.eligibility

string

Plan eligibility dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.added

string

Added date. Payers may return this information in the case of retroactive eligibility. Single date (YYYYMMDD).

planDateInformation.cobraBegin

string

The date when COBRA coverage begins. Single date (YYYYMMDD).

planDateInformation.cobraEnd

string

The date when COBRA coverage ends. Single date (YYYYMMDD).

planDateInformation.premiumPaidToDateBegin

string

The start of the period when the plan premium was paid in full. Single date (YYYYMMDD).

planDateInformation.premiumPaidToDateEnd

string

The end of period when the plan premium payments are up-to-date. Single date (YYYYMMDD).

planDateInformation.planBegin

string

The date coverage from the plan begins. Single date (YYYYMMDD).

planDateInformation.planEnd

string

The date coverage from the plan ends. Single date (YYYYMMDD).

planDateInformation.eligibilityBegin

string

The date when the patient is first eligible for benefits under the plan. Single date (YYYYMMDD).

planDateInformation.eligibilityEnd

string

The date when the patient is no longer eligible for benefits under the plan. Single date (YYYYMMDD).

planDateInformation.enrollment

string

The date when the patient is enrolled in the plan. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.admission

string

The admission date or dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.dateOfDeath

string

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

planDateInformation.certification

string

The certification date. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.service

string

The service date or dates. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.policyEffective

string

The date when the policy becomes effective. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

planDateInformation.policyExpiration

string

The date when the policy expires. Single date (YYYYMMDD).

planDateInformation.dateOfLastUpdate

string

The date when the plan information was last updated. Single date (YYYYMMDD).

planDateInformation.status

string

The status date. Single date (YYYYMMDD).

planDateInformation.periodStart

string

deprecated

The start of a period. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.periodEnd

string

deprecated

The end of a period. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.completion

string

deprecated

The completion date. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.coordinationOfBenefits

string

deprecated

The coordination of benefits date. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.benefit

string

deprecated

The benefit date. Single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD). This shape is deprecated.

planDateInformation.primaryCareProvider

string

deprecated

The primary care provider date. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.latestVisitOrConsultation

string

deprecated

The latest visit or consultation date. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.benefitBegin

string

deprecated

The benefit begin date. Single date (YYYYMMDD). This shape is deprecated.

planDateInformation.benefitEnd

string

deprecated

The benefit end date. Single date (YYYYMMDD). This shape is deprecated.

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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errors.field

string

The error type, AAA.

errors.description

string

The error description.

errors.location

string

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

errors.possibleResolutions

string

Information to help you correct the error.

errors.code

enum<string>

The error code.

Available options:

04,

15,

33,

35,

41,

42,

43,

44,

45,

46,

47,

48,

49,

50,

51,

52,

53,

54,

55,

56,

57,

58,

60,

61,

62,

63,

64,

65,

66,

67,

68,

69,

70,

71,

72,

73,

74,

75,

76,

77,

78,

79,

80,

97,

98,

AA,

AE,

AF,

AG,

AO,

CI,

E8,

IA,

MA,

T4

errors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Resubmission allowed,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

warnings

object[]

Warnings indicate non-fatal issues with your eligibility check or a non-standard response from the payer.

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warnings.code

string

The warning code.

warnings.description

string

The warning description.

status

string

Errors Stedi encountered when generating or sending the final X12 EDI transaction to the payer. These can include validation errors and payer unavailable errors that prevent delivery.

transactionSetAcknowledgement

string

The transaction set acknowledgment code provided in in the X12 EDI 999 response.

implementationTransactionSetSyntaxError

string

The implementation transaction set error code provided in IK502 of the 999 transaction.

x12

string

The raw X12 EDI 271 Eligibility Benefit Response from the payer.

planStatus

object[]

Deprecated; please use benefitsInformation.

This shape is deprecated.

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planStatus.statusCode

string

planStatus.status

string

planStatus.planDetails

string

planStatus.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

dependents

object[]

Information about dependents listed in the original eligibility check request. Note that a dependent submitted in the request may be returned in the subscriber object.

When present, this object will always include the dependent's name for identification, but many payers will also return the date of birth and other identifying information.

Information about the dependent listed in the original eligibility check request. Note that a dependent submitted in the request may be returned in the subscriber object. When present, this object will always include the dependent's name for identification, but many payers will also return the date of birth and other identifying information.

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dependents.healthCareDiagnosisCodes

object[]

Information about the patient's healthcare diagnosis.

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dependents.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.

dependents.healthCareDiagnosisCodes.diagnosisCode

string

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

dependents.memberId

string

The member ID for the subscriber's insurance policy.

dependents.firstName

string

The dependent's first name.

dependents.lastName

string

The dependent's last name.

dependents.middleName

string

The dependent's middle name or initial.

dependents.suffix

string

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

dependents.gender

enum<string>

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

Available options:

M,

F,

U

dependents.entityIdentifier

enum<string>

The entity identifier for the dependent.

Available options:

Dependent

dependents.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

dependents.uniqueHealthIdentifier

string

The dependent's unique health identifier.

dependents.dateOfBirth

string

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

dependents.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

dependents.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

dependents.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

dependents.description

string

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

dependents.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

dependents.dateTimePeriodFormatQualifier

enum<string>

The format of the military service date and time period.

Available options:

D8,

RD8

dependents.dateTimePeriod

string

The military service date, formatted as YYYYMMDD.

dependents.startDateTimePeriod

string

The military service start date, formatted as YYYYMMDD.

dependents.endDateTimePeriod

string

The military service end date, formatted as YYYYMMDD.

dependents.ssn

string

The dependent's Social Security Number (SSN).

dependents.groupNumber

string

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

dependents.planNumber

string

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

dependents.planNetworkIdNumber

string

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

dependents.groupDescription

string

Group name

dependents.planDescription

string

Plan name

dependents.planNetworkDescription

string

Plan network name

dependents.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

dependents.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

dependents.insuredIndicator

enum<string>

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

Available options:

N

dependents.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

dependents.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

dependents.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.

dependents.address

object

Show child attributes

dependents.address.address1

string

The first line of the address.

Required string length: 1 - 55

dependents.address.address2

string

The second line of the address.

Required string length: 1 - 55

dependents.address.city

string

The city.

Required string length: 2 - 30

dependents.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

dependents.address.postalCode

string

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

Required string length: 5 - 9

dependents.address.countryCode

string

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

Required string length: 2

dependents.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

dependents.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.

Show child attributes

dependents.responseProvider.providerName

string

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

dependents.responseProvider.providerFirstName

string

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

dependents.responseProvider.providerOrgName

string

The provider's organization name.

dependents.responseProvider.middleName

string

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

dependents.responseProvider.suffix

string

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

dependents.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

dependents.responseProvider.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

dependents.responseProvider.npi

string

The provider's National Provider Identifier (NPI).

dependents.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

dependents.responseProvider.referenceIdentification

string

The Health Care Provider Taxonomy Code.

dependents.responseProvider.ssn

string

The Social Security Number (SSN).

dependents.responseProvider.federalTaxpayersIdNumber

string

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

dependents.responseProvider.payorIdentification

string

The Payor Identification.

dependents.responseProvider.pharmacyProcessorNumber

string

The pharmacy processor number.

dependents.responseProvider.serviceProviderNumber

string

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

dependents.responseProvider.servicesPlanID

string

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

dependents.responseProvider.address

object

The provider's contact information.

Show child attributes

dependents.responseProvider.address.address1

string

The first line of the address.

Required string length: 1 - 55

dependents.responseProvider.address.address2

string

The second line of the address.

Required string length: 1 - 55

dependents.responseProvider.address.city

string

The city.

Required string length: 2 - 30

dependents.responseProvider.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

dependents.responseProvider.address.postalCode

string

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

Required string length: 5 - 9

dependents.responseProvider.address.countryCode

string

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

Required string length: 2

dependents.responseProvider.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

dependents.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.

dependents.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

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dependents.responseProvider.aaaErrors.field

string

The error type, AAA.

dependents.responseProvider.aaaErrors.description

string

The error description.

dependents.responseProvider.aaaErrors.location

string

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

dependents.responseProvider.aaaErrors.possibleResolutions

string

Information to help you correct the error.

dependents.responseProvider.aaaErrors.code

enum<string>

The error code.

Available options:

15,

41,

43,

44,

45,

46,

47,

48,

50,

51,

79,

97,

T4

dependents.responseProvider.aaaErrors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

dependents.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 subscriber or dependent level include missing or incorrect identifying information and that the payer was unable to locate the patient in their system. Learn more

Show child attributes

dependents.aaaErrors.field

string

The error type, AAA.

dependents.aaaErrors.description

string

The error description.

dependents.aaaErrors.location

string

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

dependents.aaaErrors.possibleResolutions

string

Information to help you correct the error.

dependents.aaaErrors.code

enum<string>

The error code.

Available options:

15,

33,

35,

42,

43,

45,

47,

48,

49,

51,

52,

53,

54,

55,

56,

57,

58,

60,

61,

62,

63,

64,

65,

66,

67,

68,

69,

70,

71,

77,

98,

AA,

AE,

AF,

AG,

AO,

CI,

E8,

IA,

MA

dependents.aaaErrors.followupAction

enum<string>

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

Available options:

Please Correct and Resubmit,

Resubmission Not Allowed,

Please Resubmit Original Transaction,

Do Not Resubmit; Inquiry Initiated to a Third Party,

Please Wait 30 Days and Resubmit,

Please Wait 10 Days and Resubmit,

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

benefitsInformation

object[]

Information about the subscriber or dependents' healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, co-pays, etc.), out of pocket maximums, and more.

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 for more information about benefit types, details about how to interpret the response, and additional examples.

Show child attributes

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

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

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

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

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

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

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

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

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.

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

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

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.

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.

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

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

benefitsInformation.benefitQuantity

string

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

benefitsInformation.authOrCertIndicator

enum<string>

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

Available options:

N,

U,

Y

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

benefitsInformation.inPlanNetworkIndicator

enum<string>

The name of the in-plan network indicator code.

Available options:

Yes,

No,

Unknown,

Not Applicable

benefitsInformation.headerLoopIdentifierCode

string

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

benefitsInformation.trailerLoopIdentifierCode

string

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

benefitsInformation.compositeMedicalProcedureIdentifier

object

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

Show child attributes

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

benefitsInformation.compositeMedicalProcedureIdentifier.productOrServiceIdQualifier

string

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

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.

benefitsInformation.compositeMedicalProcedureIdentifier.procedureModifiers

string[]

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

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.

benefitsInformation.compositeMedicalProcedureIdentifier.diagnosisCodePointer

string[]

The diagnosis code pointer.

benefitsInformation.benefitsAdditionalInformation

object

Identifying information specific to this type of benefit.

Show child attributes

benefitsInformation.benefitsAdditionalInformation.planNumber

string

The insurance plan number.

benefitsInformation.benefitsAdditionalInformation.policyNumber

string

The patient's policy number.

benefitsInformation.benefitsAdditionalInformation.memberId

string

The patient's member ID.

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.

benefitsInformation.benefitsAdditionalInformation.groupNumber

string

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

benefitsInformation.benefitsAdditionalInformation.groupDescription

string

Group name

benefitsInformation.benefitsAdditionalInformation.planDescription

string

Plan name

benefitsInformation.benefitsAdditionalInformation.planNetworkDescription

string

Plan network name

benefitsInformation.benefitsAdditionalInformation.referralNumber

string

The referral number.

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.

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.

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.

benefitsInformation.benefitsAdditionalInformation.drugFormularyNumber

string

The drug formulary number.

benefitsInformation.benefitsAdditionalInformation.priorAuthorizationNumber

string

The prior authorization number.

benefitsInformation.benefitsAdditionalInformation.insurancePolicyNumber

string

The insurance policy number.

benefitsInformation.benefitsAdditionalInformation.medicalAssistanceCategory

string

The medical assistance category.

benefitsInformation.benefitsAdditionalInformation.planNetworkIdNumber

string

The plan network identification number.

benefitsInformation.benefitsAdditionalInformation.medicaidRecepientIdNumber

string

The Medicaid Recipient Identification number.

benefitsInformation.benefitsServiceDelivery

object[]

The delivery or usage pattern for the benefits.

Show child attributes

benefitsInformation.benefitsServiceDelivery.quantityQualifierCode

enum<string>

Code specifying the type of quantity.

Available options:

DY,

FL,

HS,

MN,

VS,

Unknown

benefitsInformation.benefitsServiceDelivery.quantityQualifier

enum<string>

The name of the quantityQualifierCode. For example, Days.

Available options:

Days,

Units,

Hours,

Month,

Visits,

Unknown

benefitsInformation.benefitsServiceDelivery.quantity

string

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

benefitsInformation.benefitsServiceDelivery.unitForMeasurementCode

enum<string>

This shape is deprecated.

Available options:

Days,

Months,

Visits,

Week,

Years,

Unknown

benefitsInformation.benefitsServiceDelivery.unitForMeasurementQualifierCode

enum<string>

Code specifying the unit of measurement for the quantity.

Available options:

DA,

MO,

VS,

WK,

YR,

Unknown

benefitsInformation.benefitsServiceDelivery.unitForMeasurementQualifier

enum<string>

The name of the unitForMeasurementQualifierCode. For example, Days.

Available options:

Days,

Months,

Visits,

Week,

Years,

Unknown

benefitsInformation.benefitsServiceDelivery.sampleSelectionModulus

string

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

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

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

benefitsInformation.benefitsServiceDelivery.numOfPeriods

string

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

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

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

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

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

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

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

benefitsInformation.additionalInformation

object[]

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

Show child attributes

benefitsInformation.additionalInformation.description

string

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

benefitsInformation.eligibilityAdditionalInformationList

object[]

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

Show child attributes

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.

benefitsInformation.eligibilityAdditionalInformationList.codeListQualifier

string

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

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.

benefitsInformation.eligibilityAdditionalInformationList.industry

string

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

benefitsInformation.eligibilityAdditionalInformationList.codeCategory

string

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

benefitsInformation.eligibilityAdditionalInformationList.injuredBodyPartName

string

Description of injured body parts.

benefitsInformation.benefitsRelatedEntities

object[]

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.

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benefitsInformation.benefitsRelatedEntities.entityIdentifier

enum<string>

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

benefitsInformation.benefitsRelatedEntities.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

benefitsInformation.benefitsRelatedEntities.entityName

string

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

benefitsInformation.benefitsRelatedEntities.entityFirstname

string

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

benefitsInformation.benefitsRelatedEntities.entityMiddlename

string

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

benefitsInformation.benefitsRelatedEntities.entitySuffix

string

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

benefitsInformation.benefitsRelatedEntities.entityIdentification

enum<string>

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

benefitsInformation.benefitsRelatedEntities.entityIdentificationValue

string

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

benefitsInformation.benefitsRelatedEntities.entityRelationship

enum<string>

Code specifying the relationship between the entity and the patient.

Available options:

01,

02,

27,

41,

48,

65,

72

benefitsInformation.benefitsRelatedEntities.address

object

Show child attributes

benefitsInformation.benefitsRelatedEntities.address.address1

string

The first line of the address.

Required string length: 1 - 55

benefitsInformation.benefitsRelatedEntities.address.address2

string

The second line of the address.

Required string length: 1 - 55

benefitsInformation.benefitsRelatedEntities.address.city

string

The city.

Required string length: 2 - 30

benefitsInformation.benefitsRelatedEntities.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

benefitsInformation.benefitsRelatedEntities.address.postalCode

string

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

Required string length: 5 - 9

benefitsInformation.benefitsRelatedEntities.address.countryCode

string

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

Required string length: 2

benefitsInformation.benefitsRelatedEntities.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

benefitsInformation.benefitsRelatedEntities.contactInformation

object

Show child attributes

benefitsInformation.benefitsRelatedEntities.contactInformation.name

string

The name of the contact person.

benefitsInformation.benefitsRelatedEntities.contactInformation.contacts

object[]

The contact information.

Contacts

Show child attributes

benefitsInformation.benefitsRelatedEntities.contactInformation.contacts.communicationMode

string

The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).

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.

benefitsInformation.benefitsRelatedEntities.providerInformation

object

Show child attributes

benefitsInformation.benefitsRelatedEntities.providerInformation.providerCode

enum<string>

The provider code.

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SB,

SK,

SU,

Unknown

benefitsInformation.benefitsRelatedEntities.providerInformation.referenceIdentification

string

The provider's taxonomy code.

benefitsInformation.benefitsDateInformation

object

Dates associated with the benefits.

• Single dates are formatted as YYYYMMDD
• Date ranges are formatted as YYYYMMDD-YYYYMMDD
• Most properties contain a single date, but some can contain either a single date or a date range. Each property's documentation specifies its format.
• These dates only apply to the benefitsInformation object in which this benefitsDateInformation is provided.

Show child attributes

benefitsInformation.benefitsDateInformation.discharges

object[]

Show child attributes

benefitsInformation.benefitsDateInformation.discharges.date

string

A single date, formatted as YYYYMMDD.

benefitsInformation.benefitsDateInformation.discharges.startDate

string

The beginning date of a range, formatted as YYYYMMDD.

benefitsInformation.benefitsDateInformation.discharges.endDate

string

The end date of a range, formatted as YYYYMMDD.

benefitsInformation.benefitsDateInformation.issue

string

deprecated

The issue date. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.effectiveDateOfChange

string

deprecated

The effective date of change. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.periodStart

string

The start of a period. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.periodEnd

string

The end of a period. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.completion

string

The completion date. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.coordinationOfBenefits

string

The coordination of benefits date. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.plan

string

Only included when multiple plans apply to the patient or multiple plan periods apply. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

benefitsInformation.benefitsDateInformation.benefit

string

The benefit date. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

benefitsInformation.benefitsDateInformation.primaryCareProvider

string

The primary care provider date. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.latestVisitOrConsultation

string

The latest visit or consultation date. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.eligibility

string

Plan eligibility dates. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

benefitsInformation.benefitsDateInformation.added

string

Added date. Payers may return this information in the case of retroactive eligibility. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.cobraBegin

string

deprecated

The date when COBRA coverage begins. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.cobraEnd

string

deprecated

The date when COBRA coverage ends. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.premiumPaidtoDateBegin

string

deprecated

The start of the period when the plan premium was paid in full. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.premiumPaidToDateEnd

string

deprecated

The end of period when the plan premium payments are up-to-date. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.planBegin

string

Only included when multiple plans apply to the patient or multiple plan periods apply. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.planEnd

string

deprecated

The date coverage from the plan ends. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.benefitBegin

string

The date when the benefit begins. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.benefitEnd

string

The date when the benefit ends. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.eligibilityBegin

string

The date when the patient is first eligible for benefits under the plan. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.eligibilityEnd

string

The date when the patient is no longer eligible for benefits under the plan. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.enrollment

string

deprecated

The date when the patient is enrolled in the plan. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.admissions

object[]

Show child attributes

benefitsInformation.benefitsDateInformation.admissions.date

string

A single date, formatted as YYYYMMDD.

benefitsInformation.benefitsDateInformation.admissions.startDate

string

The beginning date of a range, formatted as YYYYMMDD.

benefitsInformation.benefitsDateInformation.admissions.endDate

string

The end date of a range, formatted as YYYYMMDD.

benefitsInformation.benefitsDateInformation.dateOfDeath

string

The date of death. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.certification

string

deprecated

The certification date. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.service

string

The service date or dates. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

benefitsInformation.benefitsDateInformation.policyEffective

string

deprecated

The date when the policy becomes effective. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.policyExpiration

string

deprecated

The date when the policy expires. Single date (YYYYMMDD). This shape is deprecated.

benefitsInformation.benefitsDateInformation.dateOfLastUpdate

string

The date when the plan information was last updated. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.status

string

The status date. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.discharge

string

The discharge date. Single date (YYYYMMDD).

benefitsInformation.benefitsDateInformation.admission

string

The admission date or dates. Can be either a single date (YYYYMMDD) or a date range (YYYYMMDD-YYYYMMDD).

benefitsInformation.benefitsRelatedEntity

object

Please use benefitsInformation.benefitsRelatedEntities instead. This shape is deprecated.

Show child attributes

benefitsInformation.benefitsRelatedEntity.entityIdentifier

enum<string>

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

benefitsInformation.benefitsRelatedEntity.entityType

enum<string>

The type of entity.

Available options:

Person,

Non-Person Entity

benefitsInformation.benefitsRelatedEntity.entityName

string

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

benefitsInformation.benefitsRelatedEntity.entityFirstname

string

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

benefitsInformation.benefitsRelatedEntity.entityMiddlename

string

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

benefitsInformation.benefitsRelatedEntity.entitySuffix

string

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

benefitsInformation.benefitsRelatedEntity.entityIdentification

enum<string>

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

benefitsInformation.benefitsRelatedEntity.entityIdentificationValue

string

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

benefitsInformation.benefitsRelatedEntity.entityRelationship

enum<string>

Code specifying the relationship between the entity and the patient.

Available options:

01,

02,

27,

41,

48,

65,

72

benefitsInformation.benefitsRelatedEntity.address

object

Show child attributes

benefitsInformation.benefitsRelatedEntity.address.address1

string

The first line of the address.

Required string length: 1 - 55

benefitsInformation.benefitsRelatedEntity.address.address2

string

The second line of the address.

Required string length: 1 - 55

benefitsInformation.benefitsRelatedEntity.address.city

string

The city.

Required string length: 2 - 30

benefitsInformation.benefitsRelatedEntity.address.state

enum<string>

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

Available options:

NL,

PE,

NS,

NB,

QC,

ON,

MB,

SK,

AB,

BC,

YT,

NT,

NU,

DC,

AS,

GU,

MP,

PR,

UM,

VI,

AK,

AL,

AR,

AZ,

CA,

CO,

CT,

DE,

FL,

GA,

HI,

IA,

ID,

IL,

IN,

KS,

KY,

LA,

MA,

MD,

ME,

MI,

MN,

MO,

MS,

MT,

NC,

ND,

NE,

NH,

NJ,

NM,

NV,

NY,

OH,

OK,

OR,

PA,

RI,

SC,

SD,

TN,

TX,

UT,

VA,

VT,

WA,

WI,

WV,

WY

benefitsInformation.benefitsRelatedEntity.address.postalCode

string

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

Required string length: 5 - 9

benefitsInformation.benefitsRelatedEntity.address.countryCode

string

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

Required string length: 2

benefitsInformation.benefitsRelatedEntity.address.countrySubDivisionCode

string

The country subdivision code from Part 2 of ISO 3166.

Required string length: 1 - 3

benefitsInformation.benefitsRelatedEntity.contactInformation

object

Show child attributes

benefitsInformation.benefitsRelatedEntity.contactInformation.name

string

The name of the contact person.

benefitsInformation.benefitsRelatedEntity.contactInformation.contacts

object[]

The contact information.

Contacts

Show child attributes

benefitsInformation.benefitsRelatedEntity.contactInformation.contacts.communicationMode

string

The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).

benefitsInformation.benefitsRelatedEntity.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.

benefitsInformation.benefitsRelatedEntity.providerInformation

object

Show child attributes

benefitsInformation.benefitsRelatedEntity.providerInformation.providerCode

enum<string>

The provider code.

Available options:

AD,

AT,

BI,

CO,

CV,

H,

HH,

LA,

OT,

P1,

P2,

PC,

PE,

R,

RF,

SB,

SK,

SU,

Unknown

benefitsInformation.benefitsRelatedEntity.providerInformation.referenceIdentification

string

The provider's taxonomy code.

benefitsInformation.eligibilityAdditionalInformation

object

Please use benefitsInformation.eligibilityAdditionalInformationList instead. This shape is deprecated.

Show child attributes

benefitsInformation.eligibilityAdditionalInformation.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.

benefitsInformation.eligibilityAdditionalInformation.codeListQualifier

string

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

benefitsInformation.eligibilityAdditionalInformation.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.

benefitsInformation.eligibilityAdditionalInformation.industry

string

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

benefitsInformation.eligibilityAdditionalInformation.codeCategory

string

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

benefitsInformation.eligibilityAdditionalInformation.injuredBodyPartName

string

Description of injured body parts.