Reading Eligibility Summaries

This guide walks you through viewing and understanding eligibility information in EDI Paisan.

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Uploading an Eligibility File

1. Go to app.edipaisan.com
2. Click Upload or drag-and-drop your 270 or 271 file
3. EDI Paisan auto-detects the transaction type

270 vs 271

• 270 — The inquiry you sent (or received to process)
• 271 — The response with actual coverage details

For verifying patient coverage, you want the 271 response.

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The Summary View

After uploading a 271, EDI Paisan displays a structured summary:

Header Section

Shows who the response is about:

Patient: SMITH, JOHN
Member ID: ABC123456789
DOB: 03/15/1985
Relationship: Self (Subscriber)

Plan: Premier PPO
Group: ACME CORPORATION
Policy #: POL789012345

Coverage Status

The most important piece — is coverage active?

Status	Meaning
✅ Active	Patient has valid coverage
❌ Inactive	Coverage not in effect
⚠️ Pending	Under review — verify with payer
🔄 Terminated	Coverage ended (check dates)

Date Range

When coverage applies:

Effective: 01/01/2024
Termination: — (ongoing)

If there's a termination date, coverage may have ended.

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Benefits Breakdown

Deductibles

How much the patient pays before insurance kicks in:

Type	Amount	Remaining
Individual In-Network	$1,500	$350
Individual Out-of-Network	$3,000	$2,100
Family In-Network	$3,000	$1,200
Family Out-of-Network	$6,000	$4,500

Remaining shows what's left to pay this period. Lower = better for patient.

Out-of-Pocket Maximum

The most the patient pays per year:

Type	Maximum	Remaining
Individual In-Network	$6,000	$4,500
Individual Out-of-Network	$12,000	$10,200

Once OOP max is met, insurance typically covers 100%.

Copays

Fixed amounts per service:

Service	In-Network	Out-of-Network
Office Visit - PCP	$25	N/A
Office Visit - Specialist	$50	N/A
Urgent Care	$75	$150
Emergency Room	$250	$250
Generic Drugs	$10	$30
Brand Drugs	$40	$80

Coinsurance

Percentage the patient pays after deductible:

Service	In-Network	Out-of-Network
Most Services	20%	40%
Inpatient Hospital	20%	50%
Mental Health	20%	50%
Durable Medical Equipment	20%	40%

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Understanding Service Types

The 271 may include benefits for specific service type codes:

Code	Service Type
30	Health Benefit Plan Coverage
1	Medical Care
2	Surgical
3	Consultation
4	Diagnostic X-Ray
5	Diagnostic Lab
6	Radiation Therapy
33	Chiropractic
35	Dental Care
47	Hospital
48	Hospital Inpatient
50	Hospital Outpatient
86	Emergency Services
88	Pharmacy
98	Professional (Physician)
MH	Mental Health
UC	Urgent Care

EDI Paisan groups related services and displays them clearly.

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Authorization Requirements

Look for auth requirements before scheduling services:

Auth Required

Service: MRI, Brain
⚠️ Prior Authorization Required
Contact: 1-800-555-AUTH
Timeframe: Call 5 business days before service

Referral Required

Service: Specialist Visit
⚠️ Referral Required
From: Primary Care Physician
Notes: Self-referral not covered

No Auth Needed

Service: Routine Lab Work
✅ No Prior Authorization Required

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Limitations & Exclusions

Visit Limits

Physical Therapy
Covered: ✅ Yes
Limit: 20 visits per calendar year
Used: 8 visits
Remaining: 12 visits

Dollar Maximums

Hearing Aids
Covered: ✅ Yes
Limit: $2,000 per 36 months
Used: $0

Exclusions

Cosmetic Surgery
Status: ❌ Not Covered
Reason: Plan exclusion

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Multiple Patients

If the 271 includes information for dependents:

Subscriber

SMITH, JOHN (Self)
Status: ✅ Active
ID: ABC123456789-01

Dependent

SMITH, MARY (Spouse)
Status: ✅ Active
ID: ABC123456789-02

SMITH, EMMA (Child)
Status: ✅ Active
ID: ABC123456789-03

Each person may have different "remaining" amounts based on services used.

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Generating PDF Reports (Pro)

Create printable eligibility summaries:

1. Upload and view the 271
2. Click Export → PDF Summary
3. Choose sections to include:
   • [ ] Patient Information
   • [ ] Coverage Status
   • [ ] Deductible/OOP Summary
   • [ ] Copay/Coinsurance Table
   • [ ] Authorization Requirements
   • [ ] Limitations & Notes
4. Click Generate PDF
5. Download or print

PDF Use Cases

Use Case	What to Include
Patient estimate	Copays, deductible remaining, OOP
Pre-auth request	Coverage status, auth requirements
Chart documentation	Full summary
Financial counseling	All cost-sharing details

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Comparing Multiple 271s

When you have eligibility responses from different dates:

Field	01/15/2024	02/15/2024
Deductible Remaining	$1,500	$1,200
OOP Remaining	$6,000	$5,500
Status	Active	Active

This shows patient has applied $300 to deductible and $500 to OOP since January.

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Troubleshooting

"Unable to determine eligibility"

The 271 contains an error or rejection:

Code	Meaning
72	Invalid/Missing Subscriber ID
73	Invalid/Missing Date of Birth
75	Subscriber Not Found
79	Invalid Participant ID

Check the 270 inquiry and resend with correct information.

Missing benefit details

Some 271s only confirm active/inactive status without full benefit breakdown. This depends on:

• What the 270 requested
• Payer's response capabilities
• Service type codes queried

Outdated information

271s are point-in-time. For current eligibility:

• Request a fresh 270
• Call payer directly
• Check payer portal

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Related Documentation

• Eligibility Summaries Overview — What you can learn from 271s
• 270 Reference — Inquiry structure
• 271 Reference — Response structure
• Pro Tier — PDF export features