Administrative Simplification Basics: Eligibility/Benefit Transactions

Administrative Simplification Basics Series: Eligibility/Benefit Transactions

Administrative Simplification includes standards for administrative and financial electronic health care transactions. Widespread use of these standards—where all trading partners use the same format and codes—can lead to substantial savings for health care organizations.

Today, we’ll review one of these transactions: eligibility/benefit inquiry and response paired transactions, also known as the X12 270/271 transaction sets.  

 Who Uses Eligibility/Benefit Transactions?

Eligibility/benefit transactions are used for:

• Inquiries about eligibility/benefits, which can be sent from a health care provider to a health plan, or from one health plan to another
• Health plan responses to inquiries about eligibility/benefits

The goal of standardized eligibility/benefit transactions is to streamline communication about a patient’s coverage information. Visit the eligibility/benefit page of the CMS Administrative Simplification website to learn more.