270/271 Eligibility and Benefit Inquiry and Response Transaction Guidelines
270/271 Eligibility and Benefit Inquiry and Response guidelines describe recommendations for HMSA partners involved in electronic documents transmission. The main requirements include the following:
- If multiple payers or multiple HMSA contracts cover a patient, the 271 response will contain multiple EB segments (where EB01 = “R” Other Payer) and corresponding NM1 segments.
- HMSA supports 270 Eligibility and Benefit inquiries for a single supported service type code, as indicated in the Companion Guide.
- If procedure code, diagnosis code, or multiple service type codes are received on 270 Eligibility inquiry, the default service type code “30” (Health Benefit Plan Coverage) will be processed.
- The current HMSA Coverage Codes will be returned on the 271 response in the EB05 Plan Coverage Description data element.
- Subscriber Date or Dependent Date can be up to 30 days from current date and no greater than 12 months in the past. If a Subscriber Date or Dependent Date is not provided on a 270 Eligibility request, current date is used to process request.
- All 270 Eligibility requests for BlueCard and FEP patients must be submitted to HMSA and not directly to the other Blue Cross and Blue Shield plan or the FEP Operations Center.
- 270 Eligibility requests for BlueCard patients should include an Information Receiver Contact Information (PER) segment to allow the other Blue Cross and Blue Shield plan to contact the provider with any questions or follow-up information.
- 271 Eligibility responses for BlueCard and FEP patients may not have the same level of detail as indicated in the Companion Document depending on the processing capabilities of the other Blue Cross and Blue Shield plan or the FEP Operations Center.
- Detailed benefit information will not be returned for Akamai Advantage, Senior Connections and QUEST Integration members. 271 Eligibility responses for Akamai Advantage, Senior Connections and QUEST Integration will contain active/inactive Eligibility information. For Benefit information on 271 Eligibility responses, EB01 value of “U” (Contact Entity for Eligibility or Benefit Information) is returned.
- 271 Eligibility Responses for Private Business, FEP and BlueCard patients will contain co-insurance, co-payment, annual deductible, annual co-payment maximum (stop loss), and benefit limitations for the latest contract within requested date range based on service type requested.
- 271 Eligibility Responses for Private Business, FEP, and Bluecard patients will contain remaining accumulation amounts for annual deductibles, annual co-payment maximum (stop loss) and certain benefit limitations for current date requests.