Eligibility Inquiry & Response

270/271 Eligibility Inquiry & Response Companion Guidelines (Health Partners)

The companion guidelines explain the procedures and requirements necessary for Trading Partners of Health Partners Plans, Inc. to transmit the following HIPAA standard transaction: 270/271 Eligibility Inquiry & Response.

The information is conveyed within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. Transmission is used in tandem with the X12N Implementation Guides and is compliant with X12 syntax and HIPAA.

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.

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.

To learn more about HIPAA EDI Transactions and become a certified EDI Professional please visit our course schedule page.

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