EDI 270/271 — Eligibility Inquiry & Response
The 270/271 transaction pair is the standard EDI mechanism for verifying a patient's health insurance eligibility and benefits before providing services.
How It Works
270 — Eligibility Inquiry (Provider → Payer)
The provider's office or billing system sends a 270 transaction to the payer containing:
- Subscriber/member ID number
- Patient name and date of birth
- Date(s) of service to verify
- Service type code (e.g., medical, dental, pharmacy)
- Provider NPI and organization information
271 — Eligibility Response (Payer → Provider)
The payer responds with a 271 transaction containing:
- Coverage status (active, inactive, terminated)
- Plan details (plan name, group number, policy type)
- Effective dates and termination dates
- Copay amounts by service type
- Deductible information (individual and family, remaining amounts)
- Coinsurance percentages
- Out-of-pocket maximum and remaining amounts
- Prior authorization requirements for specific services
- Primary care physician information
- Coordination of benefits (COB) — if other coverage exists
Real-Time vs. Batch Processing
| Mode | Description | Use Case |
|---|---|---|
| Real-time | Instant response (typically < 30 seconds) | Point-of-care verification at check-in |
| Batch | Processed in bulk, responses returned later | Pre-scheduling verification for upcoming appointments |
Most modern practice management systems and EHRs support real-time 270/271 transactions, enabling front-desk staff to verify coverage immediately.
Common Rejection Reasons
- Invalid subscriber ID — Member number not found in payer's system
- Inactive coverage — Member's plan has been terminated
- Date mismatch — Service date falls outside coverage period
- Provider not enrolled — Provider NPI not registered with the payer
- Missing required data — Incomplete demographic information
Importance in the Revenue Cycle
Eligibility verification is the first step in the revenue cycle and directly impacts:
- Claim denial rates — Verifying eligibility upfront reduces denials for inactive coverage
- Patient collections — Knowing copay/deductible amounts enables point-of-service collection
- Prior authorization — Identifying PA requirements early prevents claim denials
- Care coordination — Understanding plan type (HMO vs PPO) determines referral requirements
FHIR Equivalent
The FHIR equivalent of the 270/271 is the CoverageEligibilityRequest and CoverageEligibilityResponse resource pair, which provides the same functionality via RESTful APIs.
