POST
/
change
/
medicalnetwork
/
eligibility
/
v3
/
raw-x12
cURL
curl --request POST \
  --url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3/raw-x12 \
  --header 'Authorization: <api-key>' \
  --header 'Content-Type: application/json' \
  --data '{
  "x12": "ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1406*^*00501*000000001*0*T*>~GS*HS*SENDERGS*RECEIVERGS*20231106*140631*000000001*X*005010X279A1~ST*270*1234*005010X279A1~BHT*0022*13*10001234*20240321*1319~HL*1**20*1~NM1*PR*2*ABCDE*****PI*11122~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****SV*1999999984~HL*3*2*22*0~TRN*1*11122-12345*1234567890~NM1*IL*1*JANE*DOE****MI*123456789~DMG*D8*19000101~DTP*291*D8*20240108~EQ*MH~SE*13*1234~GE*1*000000001~IEA*1*000000001~"
}'
{
  "meta": {
    "senderId": "STEDI",
    "submitterId": "117151744",
    "applicationMode": "production",
    "traceId": "01J2VZA127GH93JT74HJU",
    "outboundTraceId": "01J2VZA127GH93JT74HJU"
  },
  "controlNumber": "1001",
  "reassociationKey": "123456789",
  "tradingPartnerServiceId": "123456789",
  "provider": {
    "providerName": "ACME HEALTH SERVICES",
    "entityIdentifier": "Provider",
    "entityType": "Non-Person Entity",
    "npi": "1999999984"
  },
  "subscriber": {
    "memberId": "123456789",
    "firstName": "JANE",
    "lastName": "DOE",
    "middleName": "A",
    "gender": "F",
    "entityIdentifier": "Insured or Subscriber",
    "entityType": "Person",
    "dateOfBirth": "19000101",
    "groupNumber": "123456789",
    "address": {
      "address1": "1234 FIRST ST",
      "city": "NEW YORK",
      "state": "WV",
      "postalCode": "123451111"
    }
  },
  "payer": {
    "entityIdentifier": "Payer",
    "entityType": "Non-Person Entity",
    "name": "ABCDE",
    "federalTaxpayersIdNumber": "123412345",
    "contactInformation": {
      "contacts": [
        {
          "communicationMode": "Telephone",
          "communicationNumber": "1234567890"
        },
        {
          "communicationMode": "Uniform Resource Locator (URL)",
          "communicationNumber": "website.company.com"
        }
      ]
    }
  },
  "planInformation": {
    "groupNumber": "12341234",
    "groupDescription": "ABCDE",
    "priorIdNumber": "1234567890"
  },
  "planDateInformation": {
    "planBegin": "20240101",
    "planEnd": "20241231",
    "eligibilityBegin": "20240102"
  },
  "planStatus": [
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "planDetails": "Open Access Plus",
      "serviceTypeCodes": [
        "30"
      ]
    },
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": [
        "A7",
        "BC",
        "A8",
        "A4",
        "A5",
        "A6",
        "7",
        "4",
        "BB",
        "22"
      ]
    },
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": [
        "MH"
      ]
    }
  ],
  "benefitsInformation": [
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "planCoverage": "Open Access Plus",
      "additionalInformation": [
        {
          "description": "Complete Care Management"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "6000",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Copay does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "500",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "3000",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        },
        {
          "description": "Copay does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "250",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "30000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "benefitPercent": "0.1",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "7500",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "benefitPercent": "0.5",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "A7",
        "BC",
        "A8",
        "A4",
        "A5",
        "A6",
        "7",
        "4",
        "BB",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric - Inpatient",
        "Day Care (Psychiatric)",
        "Psychiatric - Outpatient",
        "Psychiatric",
        "Psychiatric - Room and Board",
        "Psychotherapy",
        "Anesthesia",
        "Diagnostic X-Ray",
        "Partial Hospitalization (Psychiatric)",
        "Social Work"
      ],
      "inPlanNetworkIndicatorCode": "W",
      "inPlanNetworkIndicator": "Not Applicable"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "BC",
        "A4",
        "A6",
        "4",
        "22"
      ],
      "serviceTypes": [
        "Day Care (Psychiatric)",
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A8"
      ],
      "serviceTypes": [
        "Psychiatric - Outpatient"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "4",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "4",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Included For Specific Services"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Included For Specific Services"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "4",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "A4",
        "A6",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Social Work"
      ],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "7"
      ],
      "serviceTypes": [
        "Anesthesia"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "CB",
      "name": "Coverage Basis",
      "serviceTypeCodes": [
        "7",
        "BB"
      ],
      "serviceTypes": [
        "Anesthesia",
        "Partial Hospitalization (Psychiatric)"
      ],
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "7"
      ],
      "serviceTypes": [
        "Anesthesia"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "7"
      ],
      "serviceTypes": [
        "Anesthesia"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "4"
      ],
      "serviceTypes": [
        "Diagnostic X-Ray"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "4"
      ],
      "serviceTypes": [
        "Diagnostic X-Ray"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "BB"
      ],
      "serviceTypes": [
        "Partial Hospitalization (Psychiatric)"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "MH"
      ],
      "serviceTypes": [
        "Mental Health"
      ],
      "additionalInformation": [
        {
          "description": " Provider is out of network based on NPI ID provided in request."
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "5760",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Copay does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "500",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "2760",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        },
        {
          "description": "Copay does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "250",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "30000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "7500",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ]
    }
  ],
  "errors": [],
  "x12": "ISA*00*          *00*          *ZZ*STEDI          *01*117151744      *111111*1234*^*00501*123456782*0*P*>~GS*HB*STEDI*117151744*20240326*111000*1*X*005010X279A1~ST*271*1001*005010X279A1~BHT*0022*11*01J2VZA127GH93JT74HJU*20240326*1514~HL*1**20*1~NM1*PR*2*ABCDE*****FI*111000123~PER*IC**TE*123456789*UR*website.company.com~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****XX*1999999984~HL*3*2*22*0~NM1*IL*1*DOE*JANE*A***MI*123456789~REF*6P*123456789*ABCDE~REF*Q4*123456789~N3*1234 FIRST ST~N4*NEW YORK*WV*123451111~DMG*D8*19000101*F~INS*Y*18*001*25~DTP*356*D8*20220102~DTP*346*D8*20240101~DTP*347*D8*20241231~EB*1**30**Open Access Plus~MSG*Complete Care Management~EB*G*FAM*30***23*6000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***23*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***23*3000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***23*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***23*15000.00*****N~EB*G*FAM*30***23*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*A*IND*30*****.10****Y~EB*C*IND*30***23*7500.00*****N~EB*G*IND*30***23*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~EB*A*IND*30*****.50****N~EB*1**A7^BC^A8^A4^A5^A6^7^4^BB^22*********W~EB*C*IND*BC^A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*22~EB*C*IND*A8****0.00****N*Y~MSG*Includes services provided by Client Specific Network~EB*C*IND*A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*C*IND*A4^A6^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~III*ZZ*11~EB*A*IND*A4^A6^4^22*****.00***N*Y~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*A*IND*A4^A6^4^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*CB**7^BB********Y*Y~EB*C*IND*7****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~III*ZZ*11~EB*A*IND*4*****.00***N*Y~III*ZZ*22~EB*A*IND*4*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*22~EB*C*IND*BB****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~EB*1**MH~MSG* Provider is out of network based on NPI ID provided in request.~EB*G*FAM*30***29*5760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***29*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***29*2760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***29*15000.00*****N~EB*G*FAM*30***29*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*7500.00*****N~EB*G*IND*30***29*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~SE*119*1001~GE*1*1~IEA*1*123456782~"
}
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. This endpoint is ideal if you have an existing system that generates X12 EDI files and you want to send them through Stedi.
  1. Call this endpoint with payload in 270 X12 EDI format. Note that the request must include BHT03 (Submitter Transaction Identifier) and the Payer ID in Loop 2100A NM109. We recommend reviewing the requirements for a basic eligibility request.
  2. Stedi validates the EDI and sends the eligibility check to the payer.
  3. 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. Note that our documentation lists all enums officially allowed in the eligibility response. Some payers return non-compliant values, which Stedi passes through as is.
Visit Real-time eligibility checks for a complete how-to guide.

Authorizations

​
Authorization
string
header
required

A Stedi API Key for authentication.

Body

application/json

Response

EligibilityRawX12Check 200 response

The response is of type object.