EDI 270 – Health Care Eligibility & Benefit Inquiry
The EDI 270 Health Care Eligibility and Benefit Inquiry (270) transaction is used to inquire about
the health care eligibility and benefits associated with a subscriber or dependent. It requests
information from a healthcare insurance plan about a policy’s coverages, typically in relation to a
particular plan subscriber.
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.
The 270 documents include the following:
1-Details of the sender of the inquiry (name and contact information of the information receiver)
2-Name of the recipient of the inquiry (the information source)
3-Details of the plan subscriber about to the inquiry is referring
4-Description of eligibility or benefit information requested
For the 270, it uses multiple eligibility requests in one transaction set (ST/SE), and one
functional group (GS/GE) and one interchange (ISA/IEA) per file.
Example:
ISA ---------------------------------------------Interchange Control Header
GS ---------------------------------------------- Functional Group Header
ST -----------------------------------------------Transactional Group Header (Segment Group)
Eligibility Request
Eligibility Request
Eligibility Request
Eligibility Request
.....
SE -----------------------------------------------Transactional Set Trailer (Segment Group)
GE -----------------------------------------------Functional Group Trailer
IEA----------------------------------------------- Interchange Control Trailer
EDI 270-A1 Format Practical Example
Generic Request by a Clinic for the Patient’s (Subscriber) Eligibility
ASC X12 Version: 005010 | Transaction Set: 270/271 | TR3 ID: 005010X279
This is an example of an eligibility request from a clinic to a payer processed in Real Time. The clinic
is inquiring if the patient (the subscriber) has coverage. The request is from Bone and Joint Clinic to
the ABC Company. This example uses the Primary Search Option for a subscriber who is the patient
and is for a generic request for Eligibility.
Transmission Explanation
ST*270*1234*005010X279A1~ Transaction Set ID Code = 270
(Eligibility, Coverage or Benefit
Inquiry)
Transaction Set Control Number =
1234
Implementation Convention Reference
= 005010X279A1
BHT*0022*13*10001234*20060501*1319~ Hierarchical Structure Code = 0022
(Information Source, Information
Receiver, Subscriber, Dependent)
Transaction Set Purpose Code = 13
(Request) Identification
Reference Identification = 10001234
Date = 20060501 (May 1, 2006)
Time = 1:19 PM
HL*1**20*1~ Hierarchical ID Number = 1
Hierarchical Parent ID Number = * not
used
Hierarchical Level Code = 20
(Information Source)
Hierarchical Child Code = 1
NM1*PR*2*ABC COMPANY*****PI*842610001~ Entity Identifier Code = PR (Payer)
Entity Type Qualifier = 2 (Non-person)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI
(Payer Identification)
Identification Code = 842610001
HL*2*1*21*1~ Hierarchical ID Number = 2
Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21
Hierarchical Child Code = 1
NM1*1P*2*BONE AND JOINT Entity Identifier Code = 1P (Provider)
CLINIC*****SV*2000035~ Entity Type Qualifier = 2 (Non-person)
Last Name = Bone and Joint Clinic
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV
Service Provider Number
Identification Code = 2000035
HL*3*2*22*0~ Hierarchical ID Number = 3
Hierarchical Parent ID Number = 2
Hierarchical Level Code = 22
Hierarchical Child Code = 0
TRN*1*93175-012547*9877281234~ Trace Type Code = 1 (Current
Transaction Trace Number)
Reference Identification = 93175-
012547
Originating Company Identifier =
9877281234
Reference Identification = * not used
NM1*IL*1*SMITH*ROBERT****MI*11122333301~ Entity Identifier Code = IL (Insured or
Subscriber)
Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = Robert
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = MI
(Member Identification Number)
Identification Code = 11122333301
