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 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

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.