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EDI 271

EDI 271 Eligibility, Coverage or Benefit Information:

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 (name and 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.

For healthcare institutions, EDI Outsourcing services from 1EDISource offer an easy and cost-effective approach to managing your EDI initiatives. Let the experts at 1EDISource manage your day-to-day EDI tasks, while ensuring full compliance with HIPAA standards.

EDI 271 Specification:

This X12 Transaction Set contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Information Transaction Set (271) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be 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, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.

Accredited Standards Committee X12. ASC X12 Standard [Table Data].
Data Interchange Standards Association, Inc., Falls Church, VA.
Page Title: Learn about the EDI 271 Eligibility, Coverage or Benefit Information