270/271 Eligibility Inquiry & Response Companion HIPAA Guidelines
270/271 Eligibility Inquiry & Response guidelines contain clarifications as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standard for Electronic Transactions. Please, mention that Health Partners Plans, Inc. may make improvements and/or changes to the information contained in this blog so you should look for the updates on the official web-site. The guidelines below explain the procedures and requirements necessary for Trading Partners of Health Partners Plans, Inc. to transmit the HIPAA standard transaction 270/271 Eligibility Inquiry & Response.
Eligibility Status Request (270)
The only data elements that are required by Health Partners to identify the member are:
- Member ID
- Provider ID
The other fields on the Eligibility Request screen will be the Eligibility Start Date and Provider ID fields. If submitted, the eligibility date field will be used to determine if the member is/was eligible specifically on that date. If the eligibility start date is not submitted, the eligibility date will default to the transaction date. The provider ID identifies the provider making the inquiry.
Eligibility Status Response (271)
The following are the Eligibility Response Values utilized by Health Partners Plans:
- Member is Eligible
- Member is Not Eligible
- Member is Not Found
- Member is Invalid
For valid, eligible members, Health Partners Plans will return the member’s ID along with selected demographic information, including the member’s name and date of birth, PCP information (provider ID, name, effective date), Ob/Gyn information (same information as PCP, as available), and the member’s hospital affiliation. In the event of a member who has been terminated (not eligible), Health Partners Plans will return the member’s ID, the member’s name, and the termination date. In the event that the member is not found in Health Partners Plans’ database, Health Partners Plans will return a 271 transaction set containing an AAA segment identifying that the member was not found.
If the member is found in Health Partners Plans’ database but determined to either be an invalid member – either a “dummy member” (these are fictitious member numbers that are used for testing) or members who have been only partially entered, etc , Health Partners Plans will return a 271 transaction set containing an AAA segment identifying that the member was invalid.