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EDI 270 Format Example

EDI 270 Eligibility, Coverage of Benefit Inquiry

What is the EDI 270 Transaction Set?

The EDI 270 Healthcare Eligibility/Benefit Inquiry transaction set contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Inquiry Transaction Set specified by HIPAA 5010 standards for electronic data exchange. The 270 inquiry and the 271 response to inquiry transactions are common transaction pairs in healthcare data exchange and compliant with HIPAA 5010 Standards.

The transaction set may be used by all lines of insurance such as Health, Life, and Property and Casualty.

The EDI 270 A1 transaction set is used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber’s policy.

EDI 270 A1 Transaction Loaded Into Healthcare Data Mapping Software

EDI 270 Eligibility Inquiry in Data Mapper
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EDI 270 Workflow Example

EDI Healthcare Transaction Workflow Diagram with PilotFish Integration Engine

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X12 EDI 270 Healthcare Eligibility/Benefit Inquiry Workflow

The EDI 270 Healthcare Eligibility/Benefit Inquiry transaction set is sent to inquire about eligibility and/or benefits/coverages for individuals. An EDI 999 Implementation Acknowledgment confirms receipt of the incoming EDI 270. The insurer, sponsor, payor or clearinghouse returns an EDI 271 Healthcare Eligibility/Benefit Response transaction set providing the information.


EDI 270 A1 Format Example

Generic Request by a Clinic for the Patient’s (Subscriber) Eligibility

ASC X12 Version: 005010 | Transaction Set: 270/271 | TR3 ID: 005010X279

This is an example of an eligibility request from a clinic to a payer processed in Real Time. The clinic is inquiring if the patient (the subscriber) has coverage. The request is from Bone and Joint Clinic to the ABC Company. This example uses the Primary Search Option for a subscriber who is the patient and is for a generic request for Eligibility.

Transmission Explanation

ST*270*1234*005010X279A1~Transaction Set ID Code = 270 (Eligibility, Coverage or Benefit Inquiry)
Transaction Set Control Number = 1234
Implementation Convention Reference = 005010X279A1
BHT*0022*13*10001234*20060501*1319~Hierarchical Structure Code = 0022 (Information Source, Information Receiver, Subscriber, Dependent)
Transaction Set Purpose Code = 13 (Request) Identification
Reference Identification = 10001234
Date = 20060501 (May 1, 2006)
Time = 1:19 PM
HL*1**20*1~ Hierarchical ID Number = 1Hierarchical Parent ID Number = * not used
Hierarchical Level Code = 20 (Information Source)
Hierarchical Child Code = 1
NM1*PR*2*ABC COMPANY*****PI*842610001~Entity Identifier Code = PR (Payer)
Entity Type Qualifier = 2 (Non-person)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI (Payer Identification)
Identification Code = 842610001
HL*2*1*21*1~Hierarchical ID Number = 2
Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21
Hierarchical Child Code = 1
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~Entity Identifier Code = 1P (Provider)
Entity Type Qualifier = 2 (Non-person)
Last Name = Bone and Joint Clinic
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV Service Provider Number
Identification Code = 2000035
HL*3*2*22*0~Hierarchical ID Number = 3
Hierarchical Parent ID Number = 2
Hierarchical Level Code = 22
Hierarchical Child Code = 0
TRN*1*93175-012547*9877281234~Trace Type Code = 1 (Current Transaction Trace Number)
Reference Identification = 93175-012547
Originating Company Identifier = 9877281234
Reference Identification = * not used
NM1*IL*1*SMITH*ROBERT****MI*11122333301~Entity Identifier Code = IL (Insured or Subscriber)
Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = Robert
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = MI (Member Identification Number)
Identification Code = 11122333301
DMG*D8*19430519~Date Time Period Format = D8 (Date Expressed in Format CCYYMMDD)
Date Time Period = 19430519
DTP*291*D8*20060501~Date/Time Qualifier = 291 (Plan)
Date Time Period Format Qualifier D8 (Dates Expressed in Format CCYYMMDD)
Date Time Period = 20060501 (May 1, 2006)
EQ*30~Service Type Code = 30 (Health Benefit Plan Coverage)
SE*13*1234~Number of Included Segments = 13
Transaction Set Control Number = 1234


Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA. ASC X12 Examples

X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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