This transaction allows providers to check whether a patient has insurance coverage as of a specified date. This transaction is typically sent by healthcare service providers, such as hospitals or medical facilities, and sent to insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy. Minimum information such as Member Name, Date of birth and gender or subscriber ID is required to submit in the 270 message to get the response. If we are doing real time mode, then the expected response time will be 1 to 2 seconds.
Sample Workflow
1. Provider Smith uses ABC Billing Software aka Practice Management Software(PMS).
2. Provider Smith already signed up with XYZ Clearing House and an ID has been assigned to Provider Smith by the clearinghouse.
3. ABC Billing software has the option of generating EDI 270 messages and through web service call, it will send the message to the clearinghouse.
4. XYZ receives a message within a few seconds and then identifies the message for Payer Cigna. Since XYZ already enrolled with Payer Cigna, so it just forwards the message to Payer Cigna via web service.
5. Payer Cigna receives the message and prepares response 271 and sends it back to the clearinghouse. Immediately clearing house forward the response to the Provider Smith’s ABC billing software.
6. ABC Billing software parse the EDI 271 Message into Human-readable text and show it to the user.
Sample EDI 270 Message
ISA*00* *00* *ZZ*123123 *01*241232 *210305*0633*^*00501*111220360*1*T*:
GS*HS*123123*241232*20210305*0633*11122036*X*005010X279A1
ST*270*0001*005010X212
BHT*0022*13*0001*20210305*0633
HL*1**20*1
NM1*PR*2*CIGNA*****PI*81400
HL*2*1*21*1
NM1*1P*2*Get Well Family Clinic LLC*****46*123456789
HL*3*2*22*0
TRN*1*20201211122039*123456789
NM1*IL*1*BAKER*Alyssa****MI*723223232
DMG*D8*19981230*M
EQ*30
SE*12*0001
GE*1*11122036
IEA*1*111220360
Sample EDI271 Message
ISA|00| |00| |ZZ|XXXXXX |ZZ|XXXXXX |200824|0419|}|00501|000115778|0|P|^
GS|HB|XXXXXX|XXXXXX|20200824|0419|115778|X|005010X279A1
ST|271|0001|005010X279A1
BHT|0022|11|0001|20200824|041927
HL|1||20|1
NM1|PR|2|xxxxxxxHEALTH PLANS|||||PI|xxxxx
HL|2|1|21|1
NM1|1P|2|XXXXXX XXXXXXX LLC|||||XX|1111111111
HL|3|2|22|0
TRN|2|240804191|3030240928
TRN|2|1812481745|9ZIRMEDCOM|ELR ID
TRN|1|1438618196|9ZIRMEDCOM|ELI ID
NM1|IL|1|XXXXXX|XXXXXXX||||MI|U1111111111
N3|XXXX XXXXX xx
N4|XXXXX XXXXX|MS|33333
DMG|D8|19560201|M
DTP|636|D8|20200824
DTP|343|D8|20201231
DTP|346|D8|20200101
EB|1||30||MS BALANCE C11 94%
MSG|PLEASE CONTACT THE HEALTH PLAN FOR COVERAGE DETAILS. LIMITATIONS OR PRIOR AUTHORIZATION MAY APPLY.
LS|2120
NM1|P3|1|xxxxx|xxxxxxx||||XX|1222222222
LE|2120
EB|A|IND|30||MS BALANCE C11 94%|23||.25||||Y
EB|C|IND|30||MS BALANCE C11 94%|23|0|||||Y
EB|C|FAM|30||MS BALANCE C11 94%|23|0|||||Y
EB|G|IND|30||MS BALANCE C11 94%|23|1050|||||Y
EB|G|FAM|30||MS BALANCE C11 94%|23|2100|||||Y
SE|28|0001
GE|1|115778
IEA|1|000115778
HTML View
EDI Transaction Information
| Transaction Date | 08/24/2020 |
| Sender ID | XXXXXX |
| Receiver ID | XXXXXX |
| Batch No | 000115778 |
Receiver Information
| Name | XXXXXX XXXXXXX LLC |
| NPI | 1111111111 |
Payer Information
| Name | xxxxxxxHEALTH PLANS |
| Payer ID | xxxxx |
Subscriber Information
| Last Name | XXXXXX |
| First Name | XXXXXXX |
| Address | XXXX XXXXX xx |
| City,State-Zip | XXXXX XXXXX, MS- 33333 |
| DOB | 02/01/1956 |
| Gender | M |
| Policy# | U1111111111 |
| Plan Begin Date | 01/01/2020 |
| Last Update Date | 08/24/2020 |
Benefit Information
| Benefit Code | 1 |
| Benefit Description | Active Coverage |
| Services Covered | Health Benefit Plan Coverage |
| Plan Coverage Description | MS BALANCE C11 94% |
| Entity Type | Primary Care Provider |
| Entity Last Name | xxxxx |
| Entity First Name | xxxxxxx |
| Entity ID Type | XX |
| Entity ID Value | 1222222222 |
| Message | PLEASE CONTACT THE HEALTH PLAN FOR COVERAGE DETAILS. LIMITATIONS OR PRIOR AUTHORIZATION MAY APPLY. |
Benefit Information
| Benefit Code | A |
| Benefit Description | Co-Insurance |
| Coverage | Individual |
| Services Covered | Health Benefit Plan Coverage |
| Plan Coverage Description | MS BALANCE C11 94% |
| Time Period | Calendar Year |
| Percentage | .25 |
Benefit Information
| Benefit Code | C |
| Benefit Description | Deductible |
| Coverage | Individual |
| Services Covered | Health Benefit Plan Coverage |
| Plan Coverage Description | MS BALANCE C11 94% |
| Time Period | Calendar Year |
| Benefit Amount | 0 |
Benefit Information
| Benefit Code | C |
| Benefit Description | Deductible |
| Coverage | Family |
| Services Covered | Health Benefit Plan Coverage |
| Plan Coverage Description | MS BALANCE C11 94% |
| Time Period | Calendar Year |
| Benefit Amount | 0 |
Benefit Information
| Benefit Code | G |
| Benefit Description | Out of Pocket (Stop Loss) |
| Coverage | Individual |
| Services Covered | Health Benefit Plan Coverage |
| Plan Coverage Description | MS BALANCE C11 94% |
| Time Period | Calendar Year |
| Benefit Amount | 1050 |
Benefit Information
| Benefit Code | G |
| Benefit Description | Out of Pocket (Stop Loss) |
| Coverage | Family |
| Services Covered | Health Benefit Plan Coverage |
| Plan Coverage Description | MS BALANCE C11 94% |
| Time Period | Calendar Year |
| Benefit Amount | 2100 |
Are you looking for RESTful Web Service API to generate and parse HIPAA X12 EDI Transactions? Then here is the solution offered. Please contact me for more details : vbsenthilinnet@gmail.com
Create an account in our Nagata EDI Tool and check HIPAA X12 EDI Transactions sets.
Here is the demo link
https://demo.nagatabilling.com/NagataEDITool/login.zhtml
User Name: demo, password: demo
Take a look on the following demo
Create EDI 270 from JSON
Parse EDI 271 To HTML
Parse EDI 271 To Text
Parse EDI 271 To JSON