x12 270 Eligibility, Coverage or Benefit Inquiry

270 Specifications

This transaction set can be 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. The transaction set is intended to be used by all lines of insurance such as Health, Life, and Property and Casualty.

This transaction is typically sent by healthcare service providers, such as hospitals or medical facilities, and sent to insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy.

The 270 transaction is used for inquiries about what services are covered for particular patients (policy subscribers or their dependents), including required copay or coinsurance. It may be used to inquire about general information on coverage and benefits. It may also be used for questions about the coverage of specific benefits for a given plan, such as wheelchair rental, diagnostic lab services, physical therapy services, etc.

The 270 document typically includes the following:

⇰ Details of the sender of the inquiry (contact information of the information receiver)
⇰ Name of the recipient of the inquiry (the information source)
⇰ Details of the plan subscriber about to the inquiry is referring
⇰ Description of eligibility or benefit information requested

The 270 transaction is used in conjunction with the EDI 271 transaction. The 271 is the Health Care Eligibility/Benefit Response and is used to transmit the information requested in a 270.
Healthcare providers used to contact insurance companies by phone to verify patient coverage for services, which limited the information exchange to simple yes/no questions. The adoption of EDI 270 and 271 transactions allowed for a greater level of detail of this information exchanged electronically. It also meant a reduction in the manual entry of such information, reducing related costs.
Use of both 270 and 271 transactions allows healthcare service providers to create HIPAA-compliant files requesting eligibility details for a patient. As of March 31, 2012, healthcare providers must be compliant with version 5010 of the HIPAA EDI standards.

270 Example

ISA*00* *00* *12*ABCCOM *01*999999999 *120117*1719*U*00400*000006768*0*P~

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