270, 271 EDI relationship: senders and receivers, subscribers and dependents
270, 271 EDI transactions basic information was described in our previous blog post. Today we speak about the relationship between the participants of the 270, 271 EDI transactions process.
During 270, 271 EDI exchange provider of service can request more detailed eligibility information other than a patient’s standard eligibility. A provider of service can also get specific information of the eligibility and coverage of specific benefit types such as:
- Specific Dates of Service
- Provider Codes
- Diagnosis Codes
- Types of Facilities (Hospital, Office, Ambulatory, etc.)
- Types of Services (Inpatient, Outpatient, Rehab, etc.).
270, 271 EDI transactions Senders & Receivers
A Provider of Service generally sends their 270 Requests directly to the Insurance Company. The Insurance Company then returns the 271 Response directly back to the Provider of Service. A Provider of Service also can utilize Billing Agents, Clearing Houses or other Third Party vendor to send their 270 Requests. This is advantageous to those Providers of Service who are unable to create a compliant 270 Request. A Third Party Vendor can convert a Provider of Service’s proprietary formatted eligibility request to a compliant 270 as well as submit the request to the Insurance Company. Subsequently, a Third Party Vendor can also receive the 271 Responses back from the Insurance Company and convert it to the proprietary format the Provider of Service can use.
Insurance Companies also work with Third Party vendors allowing a high volume of 270 Requests and 271 Responses to be transferred between two organizations with larger and more consolidated files. A Third Party vendor would receive batches of 270 Requests from many Providers of Service and then send one combined file to the Insurance Company. The Insurance Company would then return the 271 Reponses back to the Third Party vendor for them to disseminate to the many Providers of Service.
270, 271 EDI transactions Subscriber/Dependent
The Subscriber is the holder of the insurance policy. Dependents are typically the spouse and children of the Subscriber. The Patient is whoever is receiving care from the Provider of Service. In the synopsis below, Jill (Wife and Mother) is the Subscriber. Jack (Husband and Father) and Jillian (Daughter) are the Dependants.
In the case where the Subscriber (Jill) is the Patient, the 270 Request would contain Jill’s information in the 2000C Subscriber Loop. If a Dependant (Jack) is the Patient, the 270 Request would still contain Jill’s information in the 2000C Subscriber Loop in addition to Jack’s information in the 2000D Dependent Loop. Since Jill is the policy holder, her information should always be contained in the 2000C Subscriber Loop so the Insurance Company can quickly identify the policy information being requested.
To get more information about EDI in the healthcare industry visit vendor-independent EDI seminars