This transaction allows providers to verify whether a patient has insurance coverage as of a specified date. It is typically sent by healthcare service providers, such as hospitals or medical facilities, to insurance companies, government agencies like Medicare or Medicaid, or other organizations that maintain policy information.
To submit a 270 message and receive a response, a minimum set of information is required, including the member’s name, date of birth, gender, or subscriber ID.
If the transaction is processed in real-time mode, the expected response time is typically 1 to 2 seconds.
Sample Workflow
- Provider Smith uses ABC Billing Software, also known as Practice Management Software (PMS).
- Provider Smith has already signed up with XYZ Clearinghouse, and the clearinghouse has assigned an ID to Provider Smith.
- ABC Billing Software has the capability to generate EDI 270 messages and, through a web service call, sends these messages to the clearinghouse.
- XYZ receives the message within a few seconds and identifies it as intended for Payer Cigna. Since XYZ is already enrolled with Payer Cigna, it simply forwards the message to Payer Cigna via a web service.
- Payer Cigna receives the message, generates an EDI 271 response, and sends it back to the clearinghouse. The clearinghouse then immediately forwards the response to Provider Smith’s ABC Billing Software.
- ABC Billing Software parses the EDI 271 message into human-readable text and displays it to the user.
What is Insurance Verification Process?
The insurance verification process is the procedure healthcare providers follow to confirm a patient's insurance coverage and benefits before delivering medical services. This ensures providers get paid and patients are aware of their financial responsibilities.
Steps in the Insurance Verification Process:
- Collect Patient Information:
- Full Name
- Date of Birth
- Insurance Provider (Payer)
- Member ID or Subscriber ID
- Policy Number
- Type of Coverage (Medical, Dental, Vision, etc.)
- Submit an EDI 270 Transaction: The provider’s system sends an EDI 270 request to the payer or a clearinghouse.
- Insurance Payer Processes the Request: The payer checks the patient's eligibility, benefits, and financial responsibility.
- Receive an EDI 271 Response: The payer responds with an EDI 271 message detailing coverage, co-pays, and deductibles.
- Analyze and Confirm Coverage: Providers review the response to determine coverage and costs.
- Communicate with the Patient (if needed): If coverage issues arise, providers may update insurance details or notify the patient of out-of-pocket costs.
Importance of Insurance Verification:
- ✔️ Prevents claim denials and rejections
- ✔️ Reduces financial risk for providers
- ✔️ Ensures patients are informed about financial responsibilities
- ✔️ Speeds up the billing and reimbursement process
By implementing a streamlined insurance verification process, healthcare providers can improve efficiency and ensure smoother revenue cycle management.
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 |
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Create EDI 270 from JSON
Parse EDI 271 To HTML
Parse EDI 271 To Text
Parse EDI 271 To JSON