Eligibility, Coverage or Benefit Information

An eligibility and benefits response transaction, the 271 is sent by health plans, insurers, or their authorized representatives to employers, brokers, providers, or other requesters to answer inquiries about an individual’s or group’s coverage status and available benefits. Typically transmitted in response to a 270 (Eligibility, Coverage or Benefit Inquiry) request, it uses the hierarchical structure (HL segment) to organize information by entity level, the Eligibility or Benefit Information segment (EB) to describe specific coverage details, and the Individual or Organizational Name segment (NM1) to identify the subscriber, dependent, or other relevant party. Additional details like dates (DTP), references (REF), and demographic information (DMG) provide context for the eligibility determination.

Consider a scenario where Midwest Manufacturing submits a 270 inquiry to Blue Cross Health Plan asking about coverage for one of its employees, Sarah Chen. Blue Cross responds with a 271 transaction confirming that Sarah is an active subscriber under the company’s group plan, effective through December 31. The response hierarchically structures the information: the plan details at the top level, followed by the subscriber level containing Sarah’s name and identifier, then nested benefit information specifying her medical, dental, and vision coverage limits, copayments, and deductibles. Blue Cross includes effective dates for each benefit type and references the original inquiry, allowing Midwest Manufacturing’s benefits administrator to instantly verify Sarah’s eligibility and share specific coverage information with her.