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270 — Eligibility Inquiry
The 270 (Health Care Eligibility/Benefit Inquiry) transaction is used to request eligibility and benefit information from a payer. Providers send 270s to verify coverage before rendering services.
Purpose
The 270 requests:
- Is this patient covered?
- What benefits are available?
- What are the cost-sharing requirements?
- Are there any coverage limitations?
It flows from provider → clearinghouse → payer, typically before or at the time of service.
Loop Structure
Loop 2000A — Information Source (HL*20)
Loop 2100A — Information Source Name (Provider)
Loop 2000B — Information Receiver (HL*21)
Loop 2100B — Information Receiver Name (Payer)
Loop 2000C — Subscriber (HL*22)
Loop 2100C — Subscriber Name
Loop 2110C — Subscriber Eligibility/Benefit Inquiry (EQ)
Loop 2000D — Dependent (HL*23)
Loop 2100D — Dependent Name
Loop 2110D — Dependent Eligibility/Benefit Inquiry (EQ)Key Segments
HL — Hierarchical Level
Establishes the inquiry structure:
HL*1**20*1~ Information Source (Provider)
HL*2*1*21*1~ Information Receiver (Payer), parent=1
HL*3*2*22*1~ Subscriber, parent=2
HL*4*3*23*0~ Dependent, parent=3| Level Code | Meaning |
|---|---|
| 20 | Information Source (who's asking) |
| 21 | Information Receiver (who's being asked) |
| 22 | Subscriber (primary insured) |
| 23 | Dependent (covered family member) |
TRN — Trace Number
Tracks the inquiry for correlation with the response:
TRN*1*TRACE12345*9PROVIDER~| Element | Position | Description |
|---|---|---|
| Trace Type | 01 | 1=Current Transaction |
| Reference ID | 02 | Your tracking number |
| Originator ID | 03 | Your identifier |
The TRN value should be returned in the 271 response to match inquiry with response.
NM1 — Entity Name
Identifies all parties:
NM1*1P*2*ABC MEDICAL GROUP*****XX*1234567890~ (Provider)
NM1*PR*2*BLUE CROSS*****PI*BCBS01~ (Payer)
NM1*IL*1*SMITH*JOHN****MI*MEM123456~ (Subscriber)
NM1*03*1*SMITH*JANE****MI*MEM123457~ (Dependent)| Entity ID | Meaning |
|---|---|
| 1P | Provider |
| PR | Payer |
| IL | Insured/Subscriber |
| 03 | Dependent |
EQ — Eligibility Inquiry
Specifies what information you're requesting:
EQ*30~ Request all eligibility info
EQ*30**FAM~ Request family-level coverage
EQ*1~ Medical care
EQ*33~ Chiropractic
EQ*35~ Dental care| Element | Position | Description |
|---|---|---|
| Service Type | 01 | What service/benefit to check |
| Composite Med Procedure | 02 | Specific procedure (optional) |
| Coverage Level | 03 | IND=Individual, FAM=Family |
Common Service Type Codes
| Code | Description |
|---|---|
| 1 | Medical Care |
| 2 | Surgical |
| 3 | Consultation |
| 4 | Diagnostic X-Ray |
| 5 | Diagnostic Lab |
| 6 | Radiation Therapy |
| 30 | Health Benefit Plan Coverage |
| 33 | Chiropractic |
| 35 | Dental Care |
| 47 | Hospital |
| 48 | Hospital Inpatient |
| 50 | Hospital Outpatient |
| 51 | Hospital Emergency Accident |
| 52 | Hospital Emergency Medical |
| 86 | Emergency Services |
| 88 | Pharmacy |
| 98 | Professional (Physician) Visit |
DTP — Date/Time
Specifies dates for the inquiry:
DTP*291*D8*20240115~ Service date
DTP*307*RD8*20240115-20240215~ Date range| Qualifier | Meaning |
|---|---|
| 291 | Plan Date |
| 307 | Eligibility/Benefit Date Range |
| 472 | Service Date |
EDI Paisan Features
Viewing
- Hierarchy navigation — Expand/collapse by Source → Receiver → Subscriber → Dependent
- Inquiry summary — Count of members and service types requested
- Service type descriptions — Human-readable service type codes
- Coverage level display — Individual vs. Family indicators
- Trace number tracking — Easy correlation with 271 responses
Analysis
| Feature | Description |
|---|---|
| Member count | Total subscribers and dependents in the file |
| Inquiry count | Total EQ segments across all members |
| Service types | List of unique service types requested |
| Rejection detection | Identify any AAA error segments |
Example 270 Structure
ISA*00* *00* *ZZ*PROVIDER *ZZ*BCBS *240115*0900*^*00501*000000001*0*P*:~
GS*HS*PROVIDER*BCBS*20240115*0900*1*X*005010X279A1~
ST*270*0001*005010X279A1~
BHT*0022*13*BATCH001*20240115*0900~
HL*1**20*1~
NM1*PR*2*BLUE CROSS BLUE SHIELD*****PI*BCBS01~
HL*2*1*21*1~
NM1*1P*2*ABC MEDICAL GROUP*****XX*1234567890~
HL*3*2*22*1~
TRN*1*TRACE001*9PROVIDER~
NM1*IL*1*SMITH*JOHN****MI*MEM123456~
DMG*D8*19850315*M~
DTP*291*D8*20240115~
EQ*30~
HL*4*3*23*0~
TRN*1*TRACE002*9PROVIDER~
NM1*03*1*SMITH*JANE****MI*MEM123457~
DMG*D8*20100520*F~
DTP*291*D8*20240115~
EQ*30~
EQ*35~
SE*20*0001~
GE*1*1~
IEA*1*000000001~This example requests:
- Eligibility for subscriber John Smith (all benefits)
- Eligibility for dependent Jane Smith (all benefits + dental)
Matching Inquiries to Responses
The TRN segment is critical for matching 270 inquiries to 271 responses:
- Include a unique TRN02 value for each member in your 270
- The payer's 271 will echo this TRN value
- Use TRN to correlate which member's eligibility you received
EDI Paisan displays TRN values prominently to facilitate this matching.
Common Issues
Missing Required Information
Payers may require:
- Provider NPI (NM1*1P with XX qualifier)
- Subscriber member ID
- Date of birth for verification
- Specific service type codes
Multiple Service Types
You can include multiple EQ segments per member to request information about different services in one inquiry.
Real-time vs. Batch
270/271 transactions can be:
- Real-time: Immediate response (seconds)
- Batch: Collected and processed in bulk (hours)
EDI Paisan handles both formats identically.
Related Documentation
- 271 Eligibility Response — Understanding the response
- Eligibility Summaries — Working with eligibility data
- Service Type Codes — Complete service type reference