972-836-7750 Request a demo Talk to an expert
Talk to an expert Request a demo Call sales 972-836-7750

X12 transaction guide · Healthcare and insurance

EDI 271 Eligibility, Coverage or Benefit Information

The X12 document health plans and other payers use to report a person's eligibility, coverage and benefits, usually in reply to a 270.

Sent by
Health plan, insurer or other information source
Received by
Healthcare provider, clearinghouse or other information receiver
Standard
ANSI ASC X12

What is an EDI 271?

The EDI 271 Eligibility, Coverage or Benefit Information is the ANSI X12 transaction set used to communicate information about, or changes to, eligibility, coverage or benefits. Information sources such as insurers, sponsors and payers send it to information receivers such as physicians, hospitals and third-party administrators.

Most 271s answer a 270 inquiry. They report whether coverage is active and can include plan details, copays, deductibles and limitations by service type. HIPAA designates the 270/271 pair as the standard for healthcare eligibility checks in the United States.

How the EDI 271 worksDiagram of the EDI 271 Eligibility, Coverage or Benefit Information. Health plan, insurer or other information source sends it to healthcare provider, clearinghouse or other information receiver. It usually follows 270. It is usually followed by 999. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BHT (Beginning of Hierarchical Transaction) and detail: the required 2000 loop with HL (Hierarchical Level). 1 optional loops are listed by their first segment.How the EDI 271 worksEligibility, Coverage or Benefit Information: who sends it, where it fits and what the standard marks required1 WHERE IT FITSUSUALLY FOLLOWS270Eligibility, Coverage orBenefit InquiryEDI 271SENDERHealth plan, insurer orother informationsourceRECEIVERHealthcare provider,clearinghouse or otherinformation receiver997 or 999 acknowledgment back, if the partners agreeUSUALLY FOLLOWED BY999ImplementationAcknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDsISA … IEAFunctional group, ID code HBGS … GETransaction set 271ST … SEHEADINGBHTBeginning of Hierarchical TransactionDETAILRequired loop 2000 · repeats many timesHLHierarchical Level+ 1 optional loop, starting with:NM1Blue box: required loop. Optional loops are listed by the segment that starts them; when a loop is used, that first segment is required. Optional segmentsoutside loops are not drawn.Structure: required segments and loops in the X12 008010 listing for the 271. Your trading partner's implementation guide adds its own requirements.
How the EDI 271 worksDiagram of the EDI 271 Eligibility, Coverage or Benefit Information. Health plan, insurer or other information source sends it to healthcare provider, clearinghouse or other information receiver. It usually follows 270. It is usually followed by 999. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BHT (Beginning of Hierarchical Transaction) and detail: the required 2000 loop with HL (Hierarchical Level). 1 optional loops are listed by their first segment.How the EDI 271 worksEligibility, Coverage or Benefit Information:who sends it, where it fits and what thestandard marks required1 WHERE IT FITSUSUALLY FOLLOWS270Eligibility, Coverage or Benefit InquiryEDI 271SENDERHealth plan,insurer or otherinformationsourceRECEIVERHealthcareprovider,clearinghouse orotherinformationreceiver997 or 999 acknowledgment back, if the partnersagreeUSUALLY FOLLOWED BY999Implementation Acknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDs (ISA… IEA)Functional group, ID code HB (GS … GE)Transaction set 271 (ST … SE)HEADINGBHTBeginning of HierarchicalTransactionDETAILRequired loop 2000 · repeatsmany timesHLHierarchical Level+ 1 optional loop, starting with:NM1Blue box: required loop. Optional loops are listedby the segment that starts them; when a loop isused, that first segment is required. Optionalsegments outside loops are not drawn.Structure: required segments and loops in the X12008010 listing for the 271. Your trading partner'simplementation guide adds its own requirements.

How to read this diagram: the top row shows who sends the 271, to whom, and which documents usually come before and after it. The lower part shows what X12 release 008010 itself requires: the envelopes around the 271 and the segments and loops the standard marks as required, area by area. Optional loops are listed by the segment that starts them rather than drawn in full. This is the standard's minimum, not a trading partner's requirement: each partner's implementation guide usually makes some optional loops mandatory, restricts the codes and may use a different release.

Expand diagram Download SVG

When it is used

  • Answering a provider's 270 eligibility inquiry
  • Reporting copays, deductibles and benefit limits
  • Reporting that a subscriber could not be found or is inactive

Where it fits in the document flow

Usually follows 270 Eligibility, Coverage or Benefit Inquiry
This document 271 Eligibility, Coverage or Benefit Information
Usually followed by 999 Implementation Acknowledgment

Structure

Mandatory segments in the 271 (X12 release 008010)

The segments X12 release 008010 marks as mandatory at their level, in order. Segments inside optional loops are needed only when the loop is used. This is the standard's requirement, not your trading partner's: each partner's implementation guide names the release it uses, adds the optional segments it requires and restricts the values. The requirement status comes from one published X12 reference listing and has not been checked against a second source.

  • ST
  • BHT
  • HL
  • NM1
  • LX
  • EB
  • III
  • LQ
  • SE

Practical example

The 271 in practice

A hospital's registration system sends a 270 for a patient arriving for an outpatient procedure. The insurer's 271 reply confirms active coverage, the remaining deductible and that the procedure requires prior authorization. Registration starts the authorization request before the procedure date.

Implementation

Implementation considerations for the 271

  • Parse benefit information by service type, as payers return detailed and varied data.
  • Handle rejection reasons, such as subscriber not found, with clear follow-up steps.
  • Store responses with the visit for audit and appeals.

How ECOM helps

Automate the 271 with ECOM

Industry

Healthcare

Secure B2B integration and file transfer for providers, suppliers, distributors and healthcare partners.

Solution

EDI Integration

Exchange X12 and EDIFACT documents with partners and integrate them directly with your ERP.

Service

Fully Managed EDI

ECOM operates your defined EDI services end to end under a service agreement.

More general questions about EDI are answered in the EDI FAQ.

Related transactions

Related healthcare and insurance documents

All 31 healthcare and insurance documents

Need help with the EDI 271?

ECOM maps, tests and monitors X12 documents for your trading partners and integrates them with your ERP.

Request a Demo Contact us