Friday, 19 April 2013

EDI 270 - 5010 Health Care Eligibility/Benefit Inquiry

If you are new to Medical Billing, then please read this article first.

If you are new to EDI, then  read the following articles

What is an EDI ?
2. EDI Transactions 

3. Understanding EDI Structure
4. EDI Instruction


For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.
Providers of medical services must currently submit health care eligibility and benefit inquiries in a variety of methods, either on paper, via phone, or electronically. The information requirements vary depending upon:

  • type of insurance plan
  • type of service performed
  • where the service is performed
  • where the inquiry is initiated
  • where the inquiry is sent

  • The Health Care Coverage, Eligibility, and Benefit transactions are designed so that inquiry submitters (information receivers) can determine (a) whether an information source organization (e.g., payer, employer, HMO) has a particular subscriber or dependent on file, and (b) the health care eligibility and/or benefit information about that subscriber and/or dependent(s). The data available through these transaction sets is used to verify an individual’s eligibility and benefits, but cannot provide a history of benefit use.
    The purpose of this implementation guide is to explain the developers’ intent when the Health Care Eligibility, Coverage, or Benefit Inquiry (270) and Health Care Eligibility, Coverage, or Benefit Information (271) transaction sets were designed and to give guidance on how they should be implemented in the health care industry. Specifically, this guide defines where data is put and when it is included for the ANSI ASC X12.281 and X12.282 transaction sets for the purpose of conveying health care eligibility and benefit information.

    This paired transaction set is comprised of two transactions: the 270, which is used to request (inquire) information, and the 271, which is used to respond with coverage, eligibility, and benefit information. The official names for these transactions are:

    ANSI ASC X12.281 - Eligibility, Coverage, or Benefit Inquiry (270)
    ANSI ASC X12.282 - Eligibility, Coverage, or Benefit Information (271)

    The 270 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 ASC X12N Specification  - 5010 Version

     1. EDI 270–5010 Documentation - ISA – Interchange Control Header
     2. EDI 270–5010 Documentation – GS – Functional Group Header
     3. EDI 270–5010 Documentation – ST – Transaction Set Header
     4. EDI 270–5010 Documentation – BHT – Beginning Of Hierarchical Transaction
     5 EDI 270–5010 Documentation – HL – Hierarchical Level
     6. EDI 270–5010 Documentation–2100A Information Source Name
     7. EDI 270–5010 Documentation–2000B Information Receiver Level
     8. EDI 270–5010 Documentation–2000B Information Receiver Name
     9. EDI 270 – 5010 Documentation-2000C Hierarchical Level
    10. EDI 270 – 5010 Documentation – Subscriber Trace Number
    11. EDI 270 – 5010 Documentation –  2100C SUBSCRIBER Name

    EDI   Examples

    Please note ; all these examples are tested against WPC First Pass software.

    You can download trial version here.

    Also, you can download the following trial version software to view/validate EDI File.

    1. EDI Notepad
    2. HIPPA Document Viewer 2
    3. On Line Validator American Coders
    4. On Line Validator EDIVance

    The following open source converts X12 EDI File to XML and 1500.
    OopFactory X12 Parser

    The following URL discuss about other open source in EDI Software.
    Comparing Open Source EDI Software

    Sample EDI 270 5010. For clear understanding, line separator are used between loops

    ISA*03*id27032743*01*XYXY2233  *ZZ*XX09211223     *01*030240928      *130829*1102*^*00501*290811021*0*T*:~
    NM1*1P*2*Bella Vista Health Center*****XX*1306849724~

    Questions or feedback are always welcome. You can email me at  


    1. I am looking for an article on EDI benefit on medical industry. I am truly pleased to read this website posts which carries lots of helpful data, thanks for providing these kinds of statistics.

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    4. Gr8 simplified concepts... but can somebody assist me what is the best and simple way to send/receive EDI-5010 270/271 transactions using RESTFul web services (java platform) or any other solution...

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