x12 271 Eligibility, Coverage or Benefit Information

271 Specifications

The EDI 271 Health Care 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.

This transaction is typically sent by insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy. It is sent to healthcare service providers, such as hospitals or medical clinics that inquire to ascertain whether and to what extent a patient is covered for certain services.

The 271 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 combination of the 270 and 271 transaction sets represent the third-most used transactions in healthcare. Adoption of these transactions replaced the use of phone or fax for requesting and providing information on a patient’s coverage under a plan. By moving to the use of EDI and these specific transactions, service providers can submit the same inquiry to multiple insurance providers and will receive information in the same standardized 271 response format.
Use of the 270 and 271 transactions also allows healthcare service providers to remain in compliance with HIPAA standards. Healthcare providers must be compliant with the latest version of the HIPAA EDI standards – version 5010 – as of March 31, 2012.

271 Example

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