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HIPAA Simplified
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.
Standards
Current Version
The current industry version of the ASC X12N Health Care Eligibility Benefit and Response (270/271) is 5010. This version was adopted under HIPAA to replace version 4010 on January 16, 2009.
The Technical Report Type 3 (TR3) ASC X12N/005010X279A1 Eligibility Inquiry and Response (270/271) can be purchased at: www.x12.org/products.
Next Published Version
The next published version of the ASC X12N Health Care Eligibility Benefit and Response (270/271) will be 7030™, Also to be published is an X12 companion document (Technical Report Type 2) entitled Code Value Usage in Eligibility Benefit Inquiry and Subsequent Response. This document provides details on code usage in the Eligibility Benefit Inquiry and Response for codes that belong to code sets external to the TR3.
See the Change Healthcare Regulatory and Standards Quarterly Update for details concerning the X12 publication schedule.
Anticipated Regulation
Immediately following publication of 7030TM, X12 will promote the TR3 to version 8010 TM and is expected to recommend the 8010 TM version to CMS for adoption under HIPAA.
Note: Following the publication of version 8010, X12 will move to an annual release cycle of TR3s. See https://x12.org/about/arc-faq for more information.
7030TM and 8010TM are trademarks of X12. All rights reserved.