EDI 271 Eligibility, Coverage of Benefit Information
What is the EDI 271 Transaction Set?
The EDI 271 Healthcare Eligibility/Benefit Response transaction set is used to provide information about healthcare policy coverages relative to a specific subscriber or the subscriber’s dependent seeking medical services. It is sent in response to a 270 inquiry transaction. The 270 inquiry and the 271 response are common transaction pairs in healthcare data exchange and compliant with HIPAA 5010 standards.
The EDI 271 A1 transaction set and format is used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as – insurers, sponsors, payors) to information receivers (such as – physicians, hospitals, repair facilities, third-party administrators, governmental agencies).
This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, co-insurance, co-pays, deductibles, exclusions, and limitations.
Read how an organization benefitted from EDI transaction integration and validation of EDI 271, EDI 837 and EDI 834 transactions in our EDI Integration Solution case study.
EDI 271 Eligibility Information in Data Mapper
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EDI 271 Workflow Example
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X12 EDI 271 Healthcare Eligibility/Benefit Response Workflow
The EDI 271 Healthcare Eligibility/Benefit Response transaction set provides information requested from an insurer, sponsor, payor or clearinghouse upon receipt of an EDI 270 Healthcare Eligibility/Benefit Inquiry. The EDI 270 is sent to inquire about eligibility and/or benefits/coverages for individuals. An EDI 999 Implementation Acknowledgment confirms receipt of the incoming EDI 270.
EDI 271 Frequently Asked Questions
In the PilotFish Data Mapper, EDI messages can be graphically constructed into specific XML representations that the EDI Transformation Module can then convert into properly structured EDI messages.
EDI 271 responses to EDI 270 inquiries are used by healthcare providers to verify coverage before administering treatment, ensuring accurate billing and claims submission. For a real-world example, read our Healthcare Benefit Manager case study.
Yes, PilotFish is equipped to manage both medical benefit eligibility and pharmacy benefit eligibility (typically part of the X12 EDI 270/271 sets) or any other X12 transaction. Our platform includes robust EDI validation tools and offers specialized expertise in clinical transaction processing.
PilotFish offers a robust, comprehensive validation engine that supports all SNIP levels and provides detailed error reporting. Our solution is highly configurable, integrates easily with existing systems, and includes exceptional customer support to help you navigate any EDI challenges.
PilotFish integrates seamlessly with existing systems through its flexible and scalable architecture. Our solution supports various integration methods, including APIs, web services, and direct database connections, ensuring smooth and efficient EDI validation processes.
Check out our EDI FAQ pages for more.
EDI 271 A1 Format Example
Response to a 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 response from a payer to a clinic. The request is from Bone and Joint Clinic to the ABC Company. This response illustrates the required components outlined in Implementation-Compliant Use of the 270/271 Transaction Set. The payer has indicated the patient (the subscriber) has active coverage for the health plan, the beginning date for their coverage with the plan, active coverage for all the benefits outlined and that they have a Primary Care Physician.
Transmission Explanation
| ST*271*4321*005010X279A1~ | Transaction Set ID Code = 271 (Eligibility, Coverage or Benefit Information) Transaction Set Control Number = 4321 Implementation Convention Reference = 005010X279A1 |
| BHT*0022*11*10001234*20060501*1319~ | Hierarchical Structure Code = 0022 (Information Source, Information Receiver, Subscriber, Dependent) Transaction Set Purpose Code = 11 (Response) Identification Reference Identification = 10001234 Date = 20060501 (May 1, 2006) Time = 1:19 PM |
| HL*1**20*1~ | Hierarchical ID Number = 1 Hierarchical 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 (Information Receiver) Hierarchical Child Code = 1 |
| NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~ | Entity Identifier Code = 1P (Provider) Entity Type Qualifier = 2 (Non-Person Entity) 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 (Subscriber) Hierarchical Child Code = 0 |
| TRN*2*93175-012547*9877281234~ | Trace Type Code = 2 (Referenced Transaction Trace Number) Reference Identification = 93175-012547 Originating Company Identifier = 9877281234 Reference Identification = * not used |
| NM1*IL*1*SMITH*JOHN****MI*123456789~ | Entity Identifier Code = IL (Insured or Subscriber) Entity Type Qualifier = 1 (Person) Last Name = Smith First Name = John Middle Name = * not used Name Prefix = * not used Name Suffix = * not used Identification Code Qualifier = MI (Member Identification) Identification Code = 123456789 |
| N3*15197 BROADWAY AVENUE*APT 215~ | Address Information = 15197 BROADWAY AVENUE Address Information = APT 215 |
| N4*KANSAS CITY*MO*64108~ | City = KANSAS CITY State or Prov Code = MO Postal Code = 64108 |
| DMG*D8*19630519*M~ | Date Time Period Format = D8 (Date Expressed in Format CCYYMMDD) Date Time Period = 19630519 Gender Code = M (Male) |
| DTP*346*D8*20060101~ | Date/Time Qualifier = 346 (Plan Begin) Date Time Period Format Qualifier D8 (Dates Expressed in Format CCYYMMDD) Date Time Period = 20060101 (January 1, 2006) |
| EB*1**30**GOLD 123 PLAN~ | Eligibility or Benefit Information Code = 1 (Active Coverage) Coverage Level Code = * not used Service Type Code = 30 (Health Benefit Plan Coverage) Insurance Type Code = * not used Plan Coverage Description = Gold 123 Plan |
| EB*L~ | Eligibility or Benefit Information Code = L (Primary Care Provider) |
| EB*1**1>33>35>47>86>88>98>AL>MH>UC~ | Eligibility or Benefit Information Code = 1 (Active Coverage) Coverage Level Code = * not used Service Type Code = 1 (Medical Care) Service Type Code = 33 (Chiropractic) Service Type Code = 35 (Dental Care) Service Type Code = 47 (Hospital) Service Type Code = 86 (Emergency Services) Service Type Code = 88 (Pharmacy) Service Type Code = 98 (Professional (Physician) Visit – Office) Service Type Code = AL (Vision (Optometry)) Service Type Code = MH (Mental Health) Service Type Code = UC (Urgent Care) |
| EB*B**1>33>35>47>86>88>98>AL>MH>UC*HM*GOLD 123 PLAN*27*10*****Y~ | Eligibility or Benefit Information Code = B (Co-Payment) Coverage Level Code = * not used Service Type Code = 1 (Medical Care) Service Type Code = 33 (Chiropractic) Service Type Code = 35 (Dental Care) Service Type Code = 47 (Hospital) Service Type Code = 86 (Emergency Services) Service Type Code = 88 (Pharmacy) Service Type Code = 98 (Professional (Physician) Visit – Office) Service Type Code = AL (Vision (Optometry)) Service Type Code = MH (Mental Health) Service Type Code = UC (Urgent Care) Insurance Type Code = HM (Health Management Organization (HMO)) Plan Coverage Description = GOLD 123 PLAN Time Period Qualifier = 27 (Visit) Monetary Value = 10 (Dollar) Percent = * not used Quantity Qualifier = * not used Quantity = * not used Yes/No Condition Or Response Code (Certification/Authorization Indicator) = * not used Yes/No Condition Or Response Code (In Plan Network Indicator) = Y (Yes – In Network) |
| EB*B**1>33>35>47>86>88>98>AL>MH>UC*HM*GOLD 123 PLAN*27*30*****N~ | Eligibility or Benefit Information Code = B (Co-Payment) Coverage Level Code = * not used Service Type Code = 1 (Medical Care) Service Type Code = 33 (Chiropractic) Service Type Code = 35 (Dental Care) Service Type Code = 47 (Hospital) Service Type Code = 86 (Emergency Services) Service Type Code = 88 (Pharmacy) Service Type Code = 98 (Professional (Physician) Visit – Office) Service Type Code = AL (Vision (Optometry)) Service Type Code = MH (Mental Health) Service Type Code = UC (Urgent Care) Insurance Type Code = HM (Health Management Organization (HMO)) Plan Coverage Description = GOLD 123 PLAN Time Period Qualifier = 27 (Visit) Monetary Value = 30 (Dollar) Percent = * not used Quantity Qualifier = * not used Quantity = * not used Yes/No Condition Or Response Code (Certification/Authorization Indicator) = * not used Yes/No Condition Or Response Code (In Plan Network Indicator) = N (No – Out of Network) |
| LS*2120~ | Loop Identifier Code = 2120 |
| NM1*P3*1*JONES*MARCUS****SV*0202034~ | Entity Identifier Code = P3 (Primary Care Provider) Entity Type Qualifier = 1 (Person) Last Name = Jones First Name = Marcus Middle Name = * not used Name Prefix = * not used Name Suffix = * not used Identification Code Qualifier = SV Service Provider Number Identification Code = 0202034 |
| LE*2120~ | Loop Identifier Code = 2120 |
| SE*22*4321~ | Number of Included Segments = 22 Transaction Set Control Number = 4321 |
Source
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.