Insurance and Benefits Eligibility Checks

This guide explains how to model your FHIR resources for the Stedi integration to send and receive eligibility and benefits checks.

Overview

The Stedi integration allows you to perform insurance eligibility checks by sending a a CoverageEligibilityRequest resource and receiving a CoverageEligibilityResponse resource with the benefits information. This workflow is handled by our Insurance Eligibility Bot. Please contact the Medplum team to get access to this bot.

For more general information about eligibility checks, please see our Insurance Eligibility Checks guide.

Creating the Eligibility Check

The following diagram shows the resources that are involved to make an insurance eligibility check with our Stedi integration.

CoverageEligibilityRequest

Field	Description	Required
insurer	Reference to the payer Organization	Yes
provider	Reference to the provider Organization	Yes
subscriber	Reference to the subscriber Patient	Yes
insurance	Array of Coverages. If there are more than one, the array item labeled as the focal will be used for the eligibility check	Yes
servicedPeriod.start	Service period start date	No (defaults to current date if not provided)
item	Array of details about the eligibility being checked. This includes what procedure, product, or service is being provided as well as why it is being provided.	No

note

In the CoverageEligibilityRequest.item field, STEDI insurance eligibility check only supports Plan Coverage and General Benefits. If it is not provided, it will default to Plan Coverage and General Benefits.

Example:

item: [
    {
      category: {
        coding: [
          {
            system: 'https://x12.org/codes/service-type-codes',
            code: '30',
            display: 'Plan Coverage and General Benefits',
          },
        ],
      },
    },
  ],

Organization (Payer)

Field	Description	Required
identifier	System must be https://www.stedi.com/healthcare/network	Yes
name	Organization name	Yes

info

If you are using an Organization from the Medplum Payer Directory, it will have the correct Payer identifier, so you can just use that.

Organization (Provider)

Field	Description	Required
identifier	System must be http://hl7.org/fhir/sid/us-npi	Yes
name	Organization name	Yes

Patient (Subscriber)

Field	Description	Required
name.family	Last name	Yes
name.given	First name	Yes
birthDate	Date of birth	Yes
identifier	System http://hl7.org/fhir/sid/us-ssn	No (but recommended)

Coverage

Field	Description	Required
subscriberId	Insurance subscriber ID	Yes
status	Should be "active"	Yes
subscriber	Reference to a Patient or RelatedPerson	Yes
beneficiary	Reference to a Patient or RelatedPerson	Yes
payor	Reference to the payer Organization	Yes

Executing the Eligibility Check

The Insurance Eligibility Bot will execute the eligibility check by sending the CoverageEligibilityRequest resource to the Stedi API.

const response = await medplum.executeBot(
    {
      system: 'https://www.medplum.com/',
      value: 'eligibility',
    },
    coverageEligibilityRequest
);

Receiving the Eligibility Response

After the eligibility check is sent, the Insurance Eligibility Bot will create and return a CoverageEligibilityResponse resource. This new CoverageEligibilityResponse will reference all of the resources from the request.

It will also contain the benefits information for the coverage in it's insurance.item field.

CoverageEligibilityResponse.insurance.item field will contain the benefits information about the patient's coverage. Read more about Receiving a CoverageEligibilityResponse.

Example CoverageEligibilityResponse from a STEDI insurance and benefits eligibility check

{
  "resourceType": "CoverageEligibilityResponse",
  "status": "active",
  "outcome": "complete", // Eligibility check was successful
  "patient": {
    "reference": "Patient/12345678-1234-5678-9abc-123456789abc",
    "display": "Jordan Doe"
  },
  "insurer": {
    "reference": "Organization/87654321-4321-8765-cdef-987654321def", 
    "display": "Aetna" // Insurance company
  },
  "insurance": [
    {
      "coverage": {
        "reference": "Coverage/abcdef12-5678-9012-3456-abcdef123456"
      },
      "inforce": true, // Coverage is active
      "benefitPeriod": {
        "start": "2024-01-01T00:00:00.000Z", // Coverage period
        "end": "2024-12-31T00:00:00.000Z"
      },
      "item": [
        // COPAY - Fixed dollar amount per visit (in-network)
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "https://www.stedi.com/in-network-indicator",
                "code": "Y",
                "display": "Yes"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in",
                "display": "In-Network"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "https://www.stedi.com/coverage-level-code",
                "code": "IND",
                "display": "Individual"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual",
                "display": "Individual"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "system": "https://www.stedi.com/benefit-type-code",
                    "code": "B",
                    "display": "Co-Payment"
                  },
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/benefit-type",
                    "code": "copay",
                    "display": "Copayment per service	"
                  }
                ]
              },
              "allowedMoney": {
                "value": 10, // $10 copay
                "currency": "USD"
              }
            }
          ]
        },

        // COINSURANCE - Percentage patient pays after deductible is met (in-network)
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "https://www.stedi.com/in-network-indicator",
                "code": "Y",
                "display": "Yes"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in",
                "display": "In-Network"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "https://www.stedi.com/coverage-level-code",
                "code": "IND",
                "display": "Individual"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual",
                "display": "Individual"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "system": "https://www.stedi.com/benefit-type-code",
                    "code": "A",
                    "display": "Co-Insurance"
                  }
                ]
              },
              "allowedUnsignedInt": 10 // 10% coinsurance
            }
          ]
        },        

        // DEDUCTIBLE - Amount before insurance contributes (in-network)
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "https://www.stedi.com/in-network-indicator",
                "code": "Y",
                "display": "Yes"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in",
                "display": "In-Network"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "https://www.stedi.com/coverage-level-code",
                "code": "IND",
                "display": "Individual"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual",
                "display": "Individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "https://www.stedi.com/time-qualifier-code",
                "code": "25", //This indicates that this is the contract's entire deductible
                "display": "Contract"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "system": "https://www.stedi.com/benefit-type-code",
                    "code": "C",
                    "display": "Deductible"
                  },
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/benefit-type",
                    "code": "deductible",
                    "display": "Deductible"
                  }
                ]
              },
              "allowedMoney": {
                "value": 500, // $500 deductible
                "currency": "USD"
              }
            }
          ]
        },

        // DEDUCTIBLE - Remaining deductible (in-network)
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "https://www.stedi.com/in-network-indicator",
                "code": "Y",
                "display": "Yes"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in",
                "display": "In-Network"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "https://www.stedi.com/coverage-level-code",
                "code": "IND",
                "display": "Individual"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual",
                "display": "Individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "https://www.stedi.com/time-qualifier-code",
                "code": "29", //This indicates that this is the remaining deductible
                "display": "Remaining"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "system": "https://www.stedi.com/benefit-type-code",
                    "code": "C",
                    "display": "Deductible"
                  },
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/benefit-type",
                    "code": "deductible",
                    "display": "Deductible"
                  }
                ]
              },
              "allowedMoney": {
                "value": 250, // $250 remaining deductible (in-network)
                "currency": "USD"
              }
            }
          ]
        },

        // OUT-OF-POCKET (STOP LOSS) - the amount of money that the patient has to pay 
        // out of pocket before the insurance covers 100% (in-network)
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-benefitcategory",
                "code": "30",
                "display": "Health Benefit Plan Coverage"
              }
            ]
          },
          "network": {
            "coding": [
              {
                "system": "https://www.stedi.com/in-network-indicator",
                "code": "Y",
                "display": "Yes"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-network",
                "code": "in",
                "display": "In-Network"
              }
            ]
          },
          "unit": {
            "coding": [
              {
                "system": "https://www.stedi.com/coverage-level-code",
                "code": "IND",
                "display": "Individual"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code": "individual",
                "display": "Individual"
              }
            ]
          },
          "term": {
            "coding": [
              {
                "system": "https://www.stedi.com/time-qualifier-code",
                "code": "29",
                "display": "Remaining"
              }
            ]
          },
          "benefit": [
            {
              "type": {
                "coding": [
                  {
                    "system": "https://www.stedi.com/benefit-type-code",
                    "code": "G",
                    "display": "Out of Pocket (Stop Loss)"
                  },
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/benefit-type",
                    "code": "benefit",
                    "display": "Benefit"
                  }
                ]
              },
              "allowedMoney": {
                "value": 7000,
                "currency": "USD"
              }
            }
          ]
        },
      ]
    },
    //You will usually get out of network benefits as well
  ]
}

Here are the STEDI specific codes that will be included in each of these fields:

Network Indicator Codes - Indicates whether a service is in-network or out-of-network (System: https://www.stedi.com/in-network-indicator)

Code	Display
Y	Yes
N	No
U	Unknown
W	Not Applicable

Coverage Level Codes - Defines who is covered under the benefit (individual, family, employee, etc.) (System: https://www.stedi.com/coverage-level-code)

Code	Display
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

Time Qualifier Codes - Specifies the time period for the benefit (calendar year, lifetime, remaining, etc.) (System: https://www.stedi.com/time-qualifier-code)

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

Benefit Type Codes - Defines the type of benefit (deductible, copay, coinsurance, coverage status, etc.) (System: https://www.stedi.com/benefit-type-code)

Code	Display
1	Active Coverage
2	Active - Full Risk Capitation
3	Active - Services Capitated
4	Active - Services Capitated to Primary Care Physician
5	Active - Pending Investigation
6	Inactive
7	Inactive - Pending Eligibility Update
8	Inactive - Pending Investigation
A	Co-Insurance
B	Co-Payment
C	Deductible
CB	Coverage Basis
D	Benefit Description
E	Exclusions
F	Limitations
G	Out of Pocket (Stop Loss)
H	Unlimited
I	Non-Covered
J	Cost Containment
K	Reserve
L	Primary Care Provider
M	Pre-existing Condition
MC	Managed Care Coordinator
O	Services Restricted to Following Provider
P	Not Deemed a Medical Necessity
Q	Benefit Disclaimer
R	Second Surgical Opinion Required
S	Other or Additional Payor
T	Prior Year(s) History
U	Card(s) Reported Lost/Stolen
V	Contact Following Entity for Eligibility or Benefit Information
W	Cannot Process
X	Other Source of Data
Y	Health Care Facility
N	Spend Down

Different Subscriber and Dependent

If the subscriber and dependent are different, for example if you are checking benefits for a spouse or child who is covered under their parent's insurance, your Coverage resource will need to reference both the subscriber and dependent Patient resources. You will need to use this model for coverage eligibility checks that are not for the subscriber themselves.

How to find the raw eligibility check data

The eligibility check data is also stored in a DocumentReference resource with an identifier that has this system: http://stedi.com/eligibility-response.