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HIPAA SIMPLIFIED

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Eligibility / Benefits

The ASC X12N Health Care Eligibility Benefit Inquiry and Response (270/271) is a paired transaction set consisting of an Inquiry (270) and a Response (271).

The Inquiry is used to request information about a patient’s eligibility and coverage for health insurance for a specific payer or health plan and the associated policy benefits. The Inquiry can be for a single date or for a date range.

The Response is used to communicate the patient’s eligibility status for coverage in the health insurance plan (or plans) for the requested date or date range.  For each plan under which the patient is covered (for example, a medical plan and a dental plan), the Response also provides details about the services which are covered; the benefits associated with those services; and financial information related to patient; for example:

  • Deductibles and remaining deductibles
  • Co-pays
  • Co-insurance
  • Out of pocket amounts
  • Exclusions
  • Limitations

The Response can include other information pertinent to the patient’s coverage, such as the patient’s primary care provider and other payers under whom the patient may have coverage.

  • Eligibility / Benefits

    • Standards

      Current Standard

      The current mandated version of the ASC X12N Health Care Eligibility Benefit and Response (270/271) is 5010.

      The Technical Report Type 3 (TR3) ASC X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) can be purchased at the ASC X12 Store.

      Anticipated Standard

      The next anticipated version of the ASC X12N Health Care Eligibility Benefit and Response (270/271) is 7030™. The public review schedule for this TR3 has not yet been determined.

      Online ASC X12 Public Review Forum

    • Companion Guides

    • Operating Rules

       Regulation

      The ASC X12N Health Care Eligibility Benefit Inquiry and Response (270/271) is subject to the Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions; Interim Final Rule adopted by the Department of Health and Human Services on July 8, 2011.

      Voluntary Certification

      CAQH CORE offers a voluntary certification program for their Eligibility (Phase I and II) Operating Rules.

      Eligibility / Claim Status Operating Rules