Eligibility troubleshooting

A list of potential errors and possible resolutions when submitting 270/271 eligibility checks.

Payer unable to find patient

Sometimes, a payer can’t return benefits information for a patient even when the patient exists in their system. This problem can occur for a couple reasons.

Multiple matching records

Payers can have multiple records of patients with the same name and date of birth. The payer cannot return benefits information unless they are able to identify a unique match within their system.

To avoid this issue, we recommend:

• Include all of the demographic information available for a patient.
• Include the patient’s member ID, if available.

Information discrepancies

There can be discrepancies between the information the provider has collected from the patient and the record the payer has in their system. These discrepancies can lead to issues returning a patient, even though a match exists. Some examples include differences in spelling the patient’s name, using a nickname instead of the full name (“Nick” vs. “Nicolas”), and accidentally transposing numbers in the date of birth.

If a request fails to return the expected member in the response, we recommend progressively sending additional eligibility check requests with fewer patient identity and demographic data elements, or different combinations of those. This allows you to identify and handle cases where there are data errors or discrepancies between payer and provider data.

Name mismatches

If the payer fails to find a matching plan member due to a name mismatch, the errors array in the response typically has the code set to one of the following values:

• 65: Invalid/Missing Patient Name
• 67: Patient Not Found
• 73: Invalid/Missing Subscriber/Insured Name
• 75: Subscriber/Insured Not Found

These error codes are set by the payer, not by Stedi, so it’s possible that other error codes could be returned.

Resolving the error may require trying different name variations until the check is successful.

• Replace any nickname or shortened name with the full legal name, for example “Robert” instead of “Bob”.
• Replace any non-English or accented characters (letters with diacritical marks) such as “Ñ” or “é” with the closest equivalent within the character restrictions. Stedi automatically replaces most such characters with the usual closest equivalent but this might not match the payer’s record. For example, the character “Đ” could be transliterated to “D” or “J” depending on the romanization system used.
• For compound names try using only one or the other part. You can also try try removing the separator, or changing the separator from hyphen to space, or vice versa. Some payers may ignore special or separator characters when performing name searches.
• If the patient has recently changed their name, for example due to marriage, then the name stated by the patient or printed on their ID card might not match the payer’s record. Try both the current and previous name.

Retry strategy

Implementing the right retry strategy for eligibility check failures saves a lot of time and money.

At a minimum, we strongly recommend automatically retrying every request that fails due to payer connectivity issues. Automatic retries resolve a significant portion of these types of failures without manual intervention.

Payer connectivity issues

We recommend implementing automatic retries for all of the following AAA error cases. These scenarios indicate temporary payer downtime, throttling, or intermittent connectivity issues:

• 42 (Unable to Respond at Current Time)
• 42 (Unable to Respond at Current Time) and 79 (Invalid Participant Identification)
• 80 (No Response received - Transaction Terminated)

Our recommended retry strategy depends on your eligibility check workflow.

Real-time eligibility checks

For real-time eligibility checks that require a response within a few minutes, we recommend:

• Wait 15 seconds before the first retry.
• Then, retry every 15 seconds for up to 2 minutes. The recommended retry window is based on what’s acceptable in real-time human workflows. For example, a patient checking in for an appointment at their doctor’s office.
• Don’t hit the payer with the same NPI ID more than once every 15 seconds. This time between requests helps you avoid payer throttling.
• If the request is still unsuccessful, fail gracefully and escalate as needed.

Scheduled eligibility checks

You may want to run scheduled or background eligibility checks to perform periodic refreshes for a patient population or when checking eligibility for upcoming appointments.

If you’re using the Batch Eligibility Check endpoint (recommended), Stedi automatically retries checks that fail due to payer connectivity issues for up to 8 hours.

If you’re submitting real-time checks that can tolerate longer wait times, we recommend:

• Wait 1 minute to perform the first retry.
• Then, exponentially increase the wait between subsequent retries to up to 30 minutes between attempts.
• We recommend retrying for at least 8 hours, but the retry window should be based on your business workflows.

Other common error cases

You should also consider the following common error cases when implementing retries:

AAA error	HTTP status	Reason	Retry Strategy
-	429	You exceeded your Stedi concurrency limit.	Retry immediately. Monitor your open concurrent requests and immediately replace any finished requests under your Stedi account limit.
79	200	Stedi successfully sent your request to the payer, but the payer rejected it.	First, retry as soon as possible with a different member and a different NPI. This helps determine whether the issue is with the original request or there is a broader issue with the payer. If you determine the issue is with the payer, follow our guidance for payer connectivity issues.
79	400	Either Stedi doesn’t recognize the payer ID you provided, or the payer is not configured for eligibility checks.	Don’t automatically retry. Fix the payer ID or contact Stedi support to resolve.

Errors

You may encounter the following types of errors when submitting eligibility requests.

Stedi payer errors

Stedi returns errors when it encounters issues with the payer ID you provided.

Error message	Possible causes and resolutions
Payer is not configured for {transaction type}. Please contact Stedi support to resolve.	Stedi does not yet support this transaction type for this payer, or there is a mis-mapping of payer IDs. Contact us with the name of the payer, and we’ll investigate the issue.
Payer connection does not support {transaction type}. Please contact Stedi support to discuss connectivity options.	Stedi has a connection to this payer, but it doesn’t currently support this functionality (real-time eligibility or claim submission). Contact us for a timeline on enabling it.
Payer is not configured. Please check our published payer list or contact Stedi support to resolve.	Stedi doesn’t recognize the payer ID you provided. Double-check the payer ID in the Stedi Payer Network, or contact us with the name of the payer, and we will help you determine the correct payer ID.
Payer is not supported. Please contact Stedi support to discuss connectivity options.	Stedi doesn’t yet have connectivity to this payer. We’re likely already working on it - contact us for details about the connectivity timeline.

The following error resulted from an unrecognized payer ID:

{
  "controlNumber": "123456789",
  "tradingPartnerServiceId": "TEST2",
  "errors": [
    {
      "code": "79",
      "description": "Invalid Participant Identification",
      "followupAction": "Please Correct and Resubmit",
      "location": "2100A",
      "possibleResolutions": "Payer TEST2 is not configured. Please check our published payer list or contact Stedi support to resolve."
    }
  ],
  "status": "ERROR"
}

Validation errors

Stedi validates the structure of your eligibility request and will not submit your request to the payer if it is missing required fields or if the data is not formatted correctly. The following Stedi validation error resulted from a missing provider object:

{
  "controlNumber": "123456789",
  "tradingPartnerServiceId": "CIGNA",
  "errors": [
    {
      "code": "33",
      "description": "Input Errors",
      "followupAction": "Please Correct and Resubmit",
      "possibleResolutions": "Missing required field: provider"
    }
  ],
  "status": "ERROR"
}

Payer AAA errors

When a payer rejects your eligibility check, the 271 response contains one or more AAA Request Validation segments that specify the reasons for the rejection and any recommended follow-up actions. Stedi includes this information in the aaaErrors object in the response JSON.

Common causes for AAA errors include:

• Missing or incorrect information for the subscriber, dependent, provider, or payer. In this case, you should correct any errors before resubmitting.
• Issues with payer enrollment. Many of these issues require that the provider contact the payer directly to resolve, due to PHI/HIPAA guidelines.
• The payer’s system is down or experiencing issues. In this case, the payer may not have actually validated the data in your request. If you receive these types of errors, you should wait a few minutes and resend the request again.

Each error contains a followupAction:

• Please Correct and Resubmit
• Resubmission Not Allowed | Note that this code doesn’t mean you should never resubmit the request. Intermediary clearinghouses may send this code when they have temporarily lost connection to the payer, so this code indicates that you should wait at least a few minutes before retrying instead of retrying immediately.
• Resubmission Allowed
• Do Not Resubmit; Inquiry Initiated to a Third Party | This code is uncommon
• Please Resubmit Original Transaction
• Please Wait 30 Days and Resubmit | This code is uncommon
• Please Wait 10 Days and Resubmit | This code is uncommon
• Do not resubmit; We Will Hold Your Request and Respond Again Shortly | This code is uncommon

AAA errors can be present at multiple different levels in the response, depending on the type. The following example shows an error at the subscriber level (subscriber.aaaErrors):

{
    "subscriber": {
        "memberId": "123456789",
        "firstName": "JANE",
        "lastName": "DOE",
        "entityIdentifier": "Insured or Subscriber",
        "entityType": "Person",
        "dateOfBirth": "19001103",
        "aaaErrors": [
            {
                "field": "AAA",
                "code": "75",
                "description": "Subscriber/Insured Not Found",
                "followupAction": "Please Correct and Resubmit",
                "location": "Loop 2100C",
                "possibleResolutions": "- Subscriber was not found."
            }
        ]
    }
}

However, all errors at the payer, provider, subscriber, and dependents levels are also reported in the top-level errors array in the eligibility check response.

Visit Eligibility mock requests to retrieve more examples of common AAA errors in eligibility responses.

Payer

You may receive the following types of errors at the payer level.

Code	Description	Possible causes and resolutions
04	Authorized Quantity Exceeded	Too many patients sent in the request.
41	Authorization/Access Restrictions	Enrollment issue with the vendor or provider’s tax ID. Issue with payer-assigned login ID. Incorrect/missing portal payer credentials.
42	Unable to Respond at Current Time	This is typically a temporary issue with the payer’s system, but it can also be an extended outage.
79	Invalid Participant Identification	There is a problem connecting with this payer. Contact Stedi support.
80	No Response received - Transaction Terminated	Payer processing issue. Transaction timed out.
T4	Payer Name or Identifier Missing	Missing payer name or ID. Payer processing issue.

Provider

You may receive the following types of errors at the provider level.

Code	Description	Possible causes and resolutions
15	Required application data missing	The request is missing required provider additional identification in informationReceiverName.
41	Authorization/Access Restrictions	Enrollment issue with the vendor or provider’s tax ID. Issue with payer-assigned login ID. Incorrect/missing portal payer credentials.
43	Invalid/Missing Provider Identification	Provider’s NPI is not registered with the payer. Provider’s NPI not registered correctly with the payer. Payer requires an agreement.
44	Invalid/Missing Provider Name	Provider’s NPI is registered with incorrect name at the payer. Provider must contact the payer directly to have this issue fixed because of PHI/HIPAA guidelines.
45	Invalid/Missing Provider Specialty	The provider’s NPI not registered with payer under correct specialty. Provider must contact payer directly to remedy this issue, due to PHI/HIPAA guidelines.
46	Invalid/Missing Provider Phone Number	Provider’s phone does not match what is registered with the payer or NPPES system for this provider. Provider must contact the payer directly to remedy this issue, due to PHI/HIPAA guidelines.
47	Invalid/Missing Provider State	The provider’s address does not match what is listed with the payer or the NPPES system. Provider must contact the payer directly to remedy this issue, due to PHI/HIPAA guidelines.
48	Invalid/Missing Referring Provider Identification Number	Referring provider’s NPI is not registered with the payer plans - provider must contact directly. Enrollment is incorrect; contact Stedi support.
50	Provider Ineligible for Inquiries	The provider is not registered for that service type with payer; provider must contact payer directly.
51	Provider Not on File	Provider is not registered with the payer; provider must contact payer directly to register their NPI.
79	Invalid Participant Identification	There is a problem connecting with this payer. Contact Stedi support.
97	Invalid or Missing Provider Address	The provider address sent in informationReceiverName.address was missing or invalid.
T4	Invalid or Missing Provider Address	Missing payer name or ID. Payer processing issue.

Subscriber

You may receive the following types of errors at the subscriber level.

Code	Description	Possible causes and resolutions
15	Required application data missing	Subscriber info may not contain enough data to complete a benefits search. Review the payer requirements in the payer’s companion guide and resubmit.
33	Input Errors	Transaction does not meet payer’s requirements. Review subscriber and/or dependent details and resubmit.
35	Out of Network	The subscriber is not in the provider’s network.
42	Unable to Respond at Current Time	This is typically a temporary issue with the payer’s system, but it can also be an extended outage or the payer is throttling your requests.
43	Invalid/Missing Provider Identification	Provider’s NPI is not registered with the payer. Provider’s NPI is not registered correctly with the payer. Payer requires an agreement.
45	Invalid/Missing Provider Specialty	Provider’s NPI not registered with the payer under correct specialty.
47	Invalid/Missing Provider State	Provider’s address does not match what is listed with the payer or the NPPES system. Provider must contact payer directly to remedy this issue, due to PHI/HIPAA guidelines.
48	Invalid/Missing Referring Provider Identification Number	Referring provider’s NPI is not registered with the payer plans. Provider must contact payer directly. Enrollment is incorrect; contact Stedi support.
49	Provider is Not Primary Care Physician	The payer doesn’t list the provider as a PCP but requires them to be one. Either the provider or the member must contact the payer to update their record before resubmitting.
51	Provider Not on File	Provider is not registered with the payer; provider must contact payer directly to register their NPI.
52	Service Dates Not Within Provider Plan Enrollment	Provider was not registered in the insured’s plan with the payer on the Date-of-Service (DOS) listed in transaction.
53	Inquired Benefit Inconsistent with Provider Type Enrollment	Provider submitting a transaction for specialty that they are not registered with the payer to perform.
54	Inappropriate Product/Service ID Qualifier	Invalid procedure code qualifier. Update the request and resubmit.
55	Inappropriate Product/Service ID	Invalid procedure code.
56	Inappropriate Date	Incorrect date or incorrect date format.
57	Invalid/Missing Date(s) of Service	The date-of-service (DOS) is not within the allowable timeframe. Date-of-service (DOS) was not included in the request, but may be required. Date-of-service (DOS) is in the future.
58	Invalid/Missing Date-of-Birth	DOB was not sent in the request and is required by the payer to locate the member.
60	Date of Birth Follows Date(s) of Service	Date-of-service (DOS) is before the DOB in which case; the transaction should be submitted with the mother’s information.
61	Date of Death Precedes Date(s) of Service	Insured died before Date-of-service (DOS) listed in the transaction; provider must correct and resubmit.
62	Date of Service Not Within Allowable Inquiry Period	Date-of-service (DOS) is outside of the accepted time frame for requests to be submitted for the payer.
63	Date of Service in Future	Some payers do not accept Date-of-service (DOS) in the future; check payer specifications.
69	Inconsistent with Patient’s Age	Diagnosis codes are inconsistent with patient’s age.
70	Inconsistent with Patient’s Gender	Procedure codes are inconsistent with patient’s gender.
71	Patient Birth Date Does Not Match That for the Patient on the Database	DOB sent in request does not match that in the payer’s database.
72	Invalid/Missing Subscriber/Insured ID	Subscriber member ID was incorrect in the request. Request does not meet the payer requirements for subscriber ID. There is another unidentified error in the request data.
73	Invalid/Missing Subscriber/Insured Name	Incorrect subscriber name submitted. Subscriber name missing. Subscriber name spelled incorrectly. Request is not meeting payer requirements for subscriber name.
74	Invalid/Missing Subscriber/Insured Gender Code	Subscriber’s gender code was not submitted. An invalid character was provided. Incorrect gender code was provided.
75	Subscriber/Insured Not Found	Subscriber was not found. Try sending a request with firstName, lastName, dateOfBirth, and memberId.
76	Duplicate Subscriber/Insured ID Number	A duplicate member ID was found in the payer’s database.
78	Subscriber/Insured Not in Group/Plan identified	Verify subscriber’s group number and resubmit.
98	Experimental Service or Procedure
Aa	Authorization Number Not Found	The priorAuthorizationNumber sent in the request was not found.
AE	Requires Primary Care Physician Authorization	Resubmit with priorAuthorizationNumber in the request.
AF	Invalid/Missing Diagnosis Code(s)	Diagnosis Code(s) is invalid format or required by the payer to complete request.
AG	Invalid/Missing Procedure Code(s)	Procedure Code(s) is invalid format or required by the payer to complete request.
AO	Additional Patient Condition Information Required
CI	Certification Information Does Not Match Patient	The priorAuthorizationNumber was found, but does not match the member sent in the request.
E8	Requires Medical Review	Contact the payer for additional information.
IA	Invalid Authorization Number Format	The priorAuthorizationNumber sent in the request was not formatted correctly.
MA	Missing Authorization Number	A referralNumber or priorAuthorizationNumber has been issued but was not sent in the request.

Dependents

You may receive the following errors at the dependents level.

Code	Description	Possible causes and resolutions
15	Required application data missing	Dependent info may not contain enough data to complete a benefits search. Review the payer requirements in the payer’s companion guide and resubmit.
33	Input Errors	Transaction does not meet payer’s requirements. Review subscriber and/or dependent details and resubmit.
35	Out of Network	The dependent is not in the provider’s network.
42	Unable to Respond at Current Time	This is typically a temporary issue with the payer’s system, but it can also be an extended outage or the payer throttling your requests.
43	Invalid/Missing Provider Identification	Provider’s NPI is not registered with the payer. Provider’s NPI not registered correctly with the payer. Payer requires an agreement.
45	Invalid/Missing Provider Specialty	Provider’s NPI not registered with the payer under correct specialty. Provider must contact payer directly to remedy this issue, due to PHI/HIPAA guidelines.
47	Invalid/Missing Provider State Specialty	Provider’s address does not match what is listed with the payer or the NPPES system. Provider must contact payer directly to remedy this issue, due to PHI/HIPAA guidelines.
48	Invalid/Missing Referring Provider Identification Number	Referring provider’s NPI is not registered with the payer plans. Provider must contact payer directly. Enrollment is incorrect; contact Stedi support.
52	Service Dates Not Within Provider Plan Enrollment	Provider was not registered in the insured’s plan with the payer on the Date-of-Service (DOS) listed in transaction.
51	Provider Not on File	Provider is not registered with the payer; provider must contact payer directly to register their NPI.
52	Service Dates Not Within Provider Plan Enrollment	Provider was not registered in the insured’s plan with the payer on the Date-of-Service (DOS) listed in transaction.
53	Inquired Benefit Inconsistent with Provider Type Enrollment	Provider submitting a transaction for specialty that they are not registered with the payer to perform.
54	Inappropriate Product/Service ID Qualifier	Invalid procedure code qualifier. Update the request and resubmit.
55	Inappropriate Product/Service ID	Invalid procedure code.
56	Inappropriate Date	Incorrect date or incorrect date format.
57	Invalid/Missing Date(s) of Service	The date-of-service (DOS) is not within the allowable timeframe. Date-of-service (DOS) was not included in the request, but may be required. Date-of-service (DOS) is in the future.
58	Invalid/Missing Date-of-Birth	DOB was not included in the request, but may be required. DOB was incorrect in the request.
60	Date of Birth Follows Date(s) of Service	Date-of-service (DOS) is before the DOB in which case; the transaction should be submitted with the mother’s information.
61	Date of Death Precedes Date(s) of Service	Insured died before Date-of-service (DOS) listed in the transaction; provider must correct and resubmit.
62	Date of Service Not Within Allowable Inquiry Period	Date-of-service (DOS) is outside of the accepted time frame for requests to be submitted for the payer.
63	Date of Service in Future	Some payers do not accept Date-of-service (DOS) in the future; check payer specifications.
64	Invalid/Missing Patient ID	Patient ID was missing and may be required by payer. Patient ID was incorrect in the request and needs to be verified with a copy of insurance card.
65	Invalid/Missing Patient Name	Patient name was not included in the request. Patient name is spelled differently in the payer database than the provider entered into the request.
66	Invalid/Missing Patient Gender Code	Invalid/missing gender type code. Invalid/missing patient.
67	Patient Not Found	Patient is not in the payer’s database. Patient is not included in the data file used for hosting. Try sending a request with firstName, lastName, dateOfBirth, and memberId.
68	Duplicate Patient ID Number	There is either a different patient with the same member ID in the payer’s database or in the hosted data file.
69	Inconsistent with Patient’s Age	Diagnosis codes are inconsistent with patient’s age.
70	Inconsistent with Patient’s Gender	Procedure codes are inconsistent with patient’s gender.
71	Patient DOB Does Not Match That for the Patient on the Database	The date-of-birth (DOB) sent in the request does not match that in the payer’s database.
77	Subscriber Found, Patient Not Found	Subscriber was found in payer’s database but the dependent’s information is not in the payer’s database.
98	Experimental Service or Procedure
AA	Authorization Number Not Found	The priorAuthorizationNumber sent in the request was not found.
AE	Requires Primary Care Physician Authorization	Resubmit with priorAuthorizationNumber in the request.
AF	Invalid/Missing Diagnosis Code(s)	Diagnosis Code(s) is invalid format or required by the payer to complete request.
AG	Invalid/Missing Procedure Code(s)	Procedure Code(s) is invalid format or required by the payer to complete request.
AO	Additional Patient Condition Information Required
CI	Certification Information Does Not Match Patient	The priorAuthorizationNumber was found, but does not match the member sent in the request.
E8	Requires Medical Review	Contact the payer for additional information.
IA	Invalid Authorization Number Format	The priorAuthorizationNumber sent in the request was not formatted correctly.
MA	Missing Authorization Number	A referralNumber or priorAuthorizationNumber has been issued but was not sent in the request.

Card Issuer Identifier (80840)

All health plans use (80840) as the first five digits of the Card Issuer Identifier.

This is a placeholder value used for standards compliance only, and you shouldn’t pass it in an electronic eligibility check. However, many providers and OCR systems accidentally pass (80840) in other eligibility check fields. For example, they may try to pass this value as a subscriber or dependent ID, causing an AAA rejection from the payer.

To prevent these types of mistakes, Stedi automatically suppresses any string containing (80840) in the following fields:

JSON	X12 EDI
subscriber.memberId	Loop 2100C NM109 Subscriber Primary Identifier
Any property in subscriber.additionalIdentification	Loop 2100C REF02 Subscriber Supplemental Identifier
Any property in dependent.additionalIdentification	Loop 2100D REF02 Dependent Supplemental Identifier

If the payer’s eligibility response returns an AAA error, Stedi returns the following warning:

The field {FIELD} contains the string "(80840)", which is a known
placeholder prefix for a field that should not be provided in {FIELD}.
We have omitted that value in the request, and the request failed.
Please locate the correct value for {FIELD} and resubmit.

To correct this error, read the documentation for the corresponding field, locate the correct value, and resubmit the eligibility check.