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EDI 271-A1 Format Example

EDI 271-A1 Eligibility, Coverage of Benefit Information


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.

EDI 271 Transaction Loaded Into Healthcare Data Mapping Software

 

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

HL7 is the registered trademark of Health Level Seven International. 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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