EDI 270 Eligibility, Coverage or Benefit Inquiry

What is an EDI 270 Eligibility, Coverage or Benefit Inquiry?

EDI 270 refers to the Electronic Data Interchange (EDI) transaction set known as the Health Care Eligibility Benefit Inquiry and Response.

It is generally used by healthcare providers, such as hospitals, to request for information regarding healthcare eligibility and benefits associated with a subscriber. The transaction set contains the following key data elements:

• Name and contact information of the sender of the inquiry
• Name of the recipient of the inquiry
• Details of the insurance plan
• Details about the eligibility or benefit information requested

When a provider sends an EDI 270 transaction, it serves as a request for information from the insurance company. The insurance company, in turn, processes the inquiry and generates an EDI 271 response transaction. This transaction contains the relevant information regarding the patient’s eligibility, coverage details, and any applicable co-pays or deductibles.

EDI 270/271 transactions help streamline the eligibility verification process, reduce paperwork, and improve healthcare billing and claims processing efficiency. These standardized electronic transactions facilitate faster communication between healthcare providers and payers, leading to more accurate and timely reimbursement.

EDI X12 270 Eligibility, Coverage or Benefit Inquiry Sample

The document is divided into functional groups that explain the contents of the transaction being conducted. The following example details the different data elements and segments that are found within the transaction set[1]:

ISA*00* *00* *ZZ*SUBMITTERID *ZZ*CMS *160127*0734*^*00501*000005014*1*P*|~
GS*HS*SUBMITTERID*CMS*20160127*073411*5014*X*005010X279A1~
ST*270*000000001*005010X279A1~
BHT*0022*13*TRANSA*20160127*073411~
HL*1**20*1~
NM1*PR*2*CMS*****PI*CMS~
HL*2*1*21*1~
NM1*1P*2*IRNAME*****XX*1234567893~
HL*3*2*22*0~
TRN*1*TRACKNUM*ABCDEFGHIJ~
NM1*IL*1*LNAME*FNAME****MI*123456789A~
DMG*D8*19400401~
DTP*291*RD8*20160101-20160327~
EQ*10^14^30^42^45^48^67^A7^AD^AE^AG^BF^BG~
EQ**HC|80061~
EQ**HC|G0117~
SE*15*000000001~
GE*1*5014~
IEA*1*000005014~

Workflow for the Exchange of an EDI 270 Eligibility, Coverage or Benefit Inquiry

Information requested in an EDI 270 transaction set is transmitted using the EDI 271 Health Care Eligibility/Benefit Response document. This helps healthcare service providers obtain important details associated with a benefit plan, such as the member ID and date of coverage. The use of EDI 270 documents increases the exchange of data electronically, reducing the need for manual entry of data.

Simplify Business Transactions with Astera EDIConnect

Astera EDIConnect is an enterprise-grade solution that enable frictionless B2B data exchange across systems. The code-free, unified platform allows you to seamlessly cover the entire EDI journey including source extraction, translation, acknowledgment generation, verification, and sending data to its destination. The intuitive, drag-and-drop UI allows even non-technical business users to handle customization of transactions, segments, elements, and validations with ease.

• Offers a visual that enables users to build complex, hierarchical EDI transactions
• Supports a wide variety of EDI standards, including ANSI X12, HIPAA, and EDIFACT
• Checks all files against the standard and custom validation rules defined for a trade partner
• Efficiently processes large volumes of EDI files regardless of complexity
• Generates technical and functional acknowledgments automatically upon receiving an EDI message
• Automates workflows using job scheduling capabilities