The Real-time eligibility check API from Stedi — 2 operation(s) for real-time eligibility check.
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openapi: 3.2.0
info:
contact:
email: healthcare@stedi.com
license:
name: Proprietary
url: https://stedi.com
title: Stedi Healthcare Real-time eligibility check API
version: '2024-04-01'
servers:
- description: Production
url: https://healthcare.us.stedi.com/2024-04-01
- description: Production (2026-06-01)
url: https://healthcare.us.stedi.com/2026-06-01
security:
- httpApiKeyAuth: []
tags:
- name: Real-time eligibility check
paths:
/change/medicalnetwork/eligibility/v3:
post:
description: Submit a real-time 270/271 eligibility check in JSON format
externalDocs:
description: Developer guide
url: https://www.stedi.com/docs/healthcare/send-eligibility-checks
operationId: EligibilityCheck
parameters:
- in: header
name: X-Forwarded-For
schema:
description: '**(CMS requests only):** Starting November 8, 2025, the Centers for Medicare & Medicaid Services (CMS) requires submitters to include network IP addresses from an eligibility request''s point of origin through receipt by the HETS system. To comply with this requirement, you may need to include this header in requests to CMS.
When present, this header should contain a comma-separated list of upstream IP addresses, starting with the originating system and continuing through every intermediary. You can exclude your IP address from the list. Note that Stedi blocks eligibility requests to CMS when any IP address in the chain – the originating IP address or any in the X-Forwarded-For header – is located outside the United States.
Visit [CMS traceability requirements](https://www.stedi.com/docs/healthcare/send-eligibility-checks#cms-traceability-requirements) for details and examples.'
type: string
requestBody:
content:
application/json:
examples:
EligibilityCheck_example1:
description: ''
summary: Eligibility check
value:
dependents:
- dateOfBirth: '19521121'
firstName: Jane
lastName: Doe
encounter:
serviceTypeCodes:
- '30'
provider:
npi: '1999999984'
organizationName: Provider Name
subscriber:
firstName: John
lastName: Doe
memberId: UHC202649
tradingPartnerServiceId: '87726'
EligibilityCheck_example2:
description: ''
summary: Invalid provider name
value:
provider:
npi: '1447848577'
organizationName: SIMPSON
subscriber:
dateOfBirth: '20240606'
firstName: Abe
lastName: Stedi
tradingPartnerServiceId: BS001
schema:
$ref: '#/components/schemas/EligibilityCheckRequestContent'
required: true
responses:
'200':
content:
application/json:
examples:
EligibilityCheck_example1:
description: ''
summary: Eligibility check
value:
benefitsInformation:
- additionalInformation:
- description: PROVIDER IS OUT NETWORK FOR MEMBER
- description: FUNDING TYPE = SELF INSURED - LARGE GROUP
benefitsDateInformation:
dateOfLastUpdate: '20240731'
benefitsRelatedEntities:
- address:
address1: P.O. BOX 30555
city: SALT LAKE CITY
postalCode: '841300555'
state: UT
contactInformation:
contacts:
- communicationMode: Uniform Resource Locator (URL)
communicationNumber: WWW.UHCPROVIDER.COM
entityIdentification: PI
entityIdentificationValue: '87726'
entityIdentifier: Payer
entityName: UNITEDHEALTHCARE
entityType: Non-Person Entity
benefitsRelatedEntity:
address:
address1: P.O. BOX 30555
city: SALT LAKE CITY
postalCode: '841300555'
state: UT
contactInformation:
contacts:
- communicationMode: Uniform Resource Locator (URL)
communicationNumber: WWW.UHCPROVIDER.COM
entityIdentification: PI
entityIdentificationValue: '87726'
entityIdentifier: Payer
entityName: UNITEDHEALTHCARE
entityType: Non-Person Entity
code: '1'
inPlanNetworkIndicator: Not Applicable
inPlanNetworkIndicatorCode: W
insuranceType: Commercial
insuranceTypeCode: C1
name: Active Coverage
planCoverage: CHOICE PLUS
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
- additionalInformation:
- description: HIGHEST BENEFIT
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: HIGHEST BENEFIT
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: HIGHEST BENEFIT
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Year to Date
timeQualifierCode: '24'
- additionalInformation:
- description: HIGHEST BENEFIT
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Remaining
timeQualifierCode: '29'
- additionalInformation:
- description: HIGHEST BENEFIT
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Year to Date
timeQualifierCode: '24'
- additionalInformation:
- description: HIGHEST BENEFIT
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Remaining
timeQualifierCode: '29'
- additionalInformation:
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '3200'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: Not Applicable
inPlanNetworkIndicatorCode: W
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Year to Date
timeQualifierCode: '24'
- additionalInformation:
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '5555.16'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: Not Applicable
inPlanNetworkIndicatorCode: W
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Year to Date
timeQualifierCode: '24'
- additionalInformation:
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '15500'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'No'
inPlanNetworkIndicatorCode: N
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '6850'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '3200'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '0'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Remaining
timeQualifierCode: '29'
- additionalInformation:
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '5000'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'No'
inPlanNetworkIndicatorCode: N
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '1294.84'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Remaining
timeQualifierCode: '29'
- additionalInformation:
- description: OOP MAXIMUM IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '9944.84'
code: G
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'No'
inPlanNetworkIndicatorCode: N
insuranceType: Commercial
insuranceTypeCode: C1
name: Out of Pocket (Stop Loss)
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Remaining
timeQualifierCode: '29'
- additionalInformation:
- description: DEDUCTIBLE IS MET WHEN FAMILY AMOUNT IS SATISFIED
benefitAmount: '1800'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'No'
inPlanNetworkIndicatorCode: N
name: Deductible
serviceTypeCodes:
- '30'
serviceTypes:
- Health Benefit Plan Coverage
timeQualifier: Remaining
timeQualifierCode: '29'
- additionalInformation:
- description: HIGHEST BENEFIT
code: '1'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Active Coverage
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
- additionalInformation:
- description: ABLETO FULLY FUNDED
code: '1'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Active Coverage
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
- additionalInformation:
- description: ABLETO PARTIALLY FUNDED
code: '1'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Active Coverage
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
- code: '1'
inPlanNetworkIndicator: Not Applicable
inPlanNetworkIndicatorCode: W
name: Active Coverage
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
- benefitPercent: '0.4'
code: A
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'No'
inPlanNetworkIndicatorCode: N
name: Co-Insurance
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- benefitPercent: '0.2'
code: A
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Insurance
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: HIGHEST BENEFIT
benefitPercent: '0.2'
code: A
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Insurance
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: ABLETO PARTIALLY FUNDED
benefitPercent: '0.2'
code: A
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Insurance
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: ABLETO FULLY FUNDED
benefitPercent: '0'
code: A
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Insurance
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: HIGHEST BENEFIT
benefitAmount: '0'
code: B
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Payment
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: ABLETO PARTIALLY FUNDED
benefitAmount: '0'
code: B
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Payment
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- benefitAmount: '0'
code: B
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: Not Applicable
inPlanNetworkIndicatorCode: W
name: Co-Payment
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: ABLETO FULLY FUNDED
benefitAmount: '0'
code: B
coverageLevel: Individual
coverageLevelCode: IND
eligibilityAdditionalInformation:
codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
eligibilityAdditionalInformationList:
- codeListQualifier: Mutually Defined
codeListQualifierCode: ZZ
industry: Office
industryCode: '11'
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Co-Payment
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- benefitAmount: '0'
code: C
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: ABLETO FULLY FUNDED
benefitAmount: '0'
code: C
coverageLevel: Family
coverageLevelCode: FAM
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Deductible
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Calendar Year
timeQualifierCode: '23'
- additionalInformation:
- description: ABLETO PARTIALLY FUNDED
benefitAmount: '0'
code: F
coverageLevel: Individual
coverageLevelCode: IND
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Limitations
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: HIGHEST BENEFIT
benefitAmount: '0'
code: F
coverageLevel: Individual
coverageLevelCode: IND
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Limitations
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- additionalInformation:
- description: ABLETO FULLY FUNDED
benefitAmount: '0'
code: F
coverageLevel: Individual
coverageLevelCode: IND
inPlanNetworkIndicator: 'Yes'
inPlanNetworkIndicatorCode: Y
name: Limitations
serviceTypeCodes:
- A6
serviceTypes:
- Psychotherapy
timeQualifier: Visit
timeQualifierCode: '27'
- benefitAmount: '0'
code: F
coverageLevel: Individual
coverageLevelCode: IND
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