271 — Eligibility Response

The 271 (Health Care Eligibility/Benefit Response) transaction is the payer's answer to a 270 eligibility inquiry. It contains detailed information about coverage status, benefits, cost-sharing, and any limitations.

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Purpose

The 271 provides:

• Coverage status (active, inactive, terminated)
• Plan details (name, group number, policy number)
• Benefit specifics (deductibles, copays, coinsurance)
• Coverage limitations (visit limits, dollar maximums)
• Effective and termination dates
• Error information if the inquiry couldn't be processed

It flows from payer → clearinghouse → provider in response to a 270 inquiry.

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Loop Structure

Loop 2000A — Information Source (HL*20)
  Loop 2100A — Information Source Name
  Loop 2000B — Information Receiver (HL*21)
    Loop 2100B — Information Receiver Name
    Loop 2000C — Subscriber (HL*22)
      Loop 2100C — Subscriber Name
      Loop 2110C — Subscriber Eligibility/Benefit Information (EB)
      Loop 2000D — Dependent (HL*23)
        Loop 2100D — Dependent Name
        Loop 2110D — Dependent Eligibility/Benefit Information (EB)

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Key Segments

EB — Eligibility/Benefit Information

The core segment containing benefit details:

EB*1**30**PREMIER PLAN~
EB*C*IND*30*HM**23**200~
EB*G*IND*30***25*****Y~

Element	Position	Description	Example
Benefit Type	01	Type of benefit info	1, C, G, A
Coverage Level	02	IND=Individual, FAM=Family	IND
Service Type	03	What service applies	30 (all)
Insurance Type	04	HM=HMO, PP=PPO, etc.	HM
Plan Description	05	Plan name	PREMIER PLAN
Time Period	06	23=Calendar Year, etc.	23
Amount	07	Dollar amount	200
Percentage	08	Percentage (as decimal)	25
Auth Required	11	Y=Yes, N=No	Y
In Network	12	Y=Yes, N=No

Benefit Type Codes (EB01)

Code	Meaning	What It Tells You
1	Active Coverage	Patient is covered
2	Active - Full Risk Capitation	Covered under capitation
3	Active - Services Capitated	Some services capitated
4	Active - Services Capitated to Primary Care	PCP capitation
5	Active - Pending Investigation	Coverage under review
6	Inactive	Coverage not active
7	Inactive - Pending Eligibility Update	Status changing
8	Inactive - Pending Investigation	Under review, not active
A	Co-Insurance	Patient's percentage responsibility
B	Co-Payment	Fixed amount per visit/service
C	Deductible	Amount before insurance pays
D	Benefit Description	General benefit info
E	Exclusions	What's NOT covered
F	Limitations	Coverage restrictions
G	Out of Pocket (Stop Loss)	Maximum patient pays
H	Unlimited	No benefit limit
I	Non-Covered	Service not covered
J	Cost Containment	Managed care requirements
K	Reserve	Lifetime reserve days
L	Primary Care Provider	PCP assignment
M	Pre-existing Condition	Waiting period info
MC	Managed Care Coordinator	Care coordinator info
P	Benefit Disclaimer	Important notices
R	Other/Additional Payor	Secondary coverage
U	Contact Following Entity	Who to contact
W	Other Source of Data	Alternative info source
Y	Spend Down	Amount to spend before eligible

Coverage Level Codes (EB02)

Code	Meaning
IND	Individual
FAM	Family
CHD	Children Only
DEP	Dependents Only
EMP	Employee Only
ESP	Employee and Spouse
ECH	Employee and Children

Time Period Qualifier (EB06)

Code	Meaning
6	Hour
7	Day
21	Years
22	Service Year
23	Calendar Year
24	Year to Date
25	Contract
26	Episode
27	Visit
28	Outlier
29	Remaining
30	Exceeded
31	Not Exceeded

DTP — Date/Time Periods

Dates associated with benefits:

DTP*291*D8*20240101~    Plan begin date
DTP*292*D8*20241231~    Plan end date
DTP*307*RD8*20240101-20241231~  Date range

Qualifier	Meaning
291	Plan Begin
292	Plan End
307	Eligibility Date Range
346	Plan Renewal Date
347	Enrollment Date
348	Premium Paid to Date

AAA — Request Validation

Error information when inquiry fails:

AAA*N*75**C~

Element	Position	Description
Valid Request	01	Y=Yes, N=No
Agency Code	02	Agency qualifier
Reject Reason	03	Reason code
Follow-up Action	04	What to do next

Common Reject Reason Codes (AAA03)

Code	Description
15	Required data element missing
33	Input errors
42	Unable to respond at current time
43	Invalid/missing Provider ID
58	Invalid/missing Date of Birth
60	Date of birth follows date(s) of service
61	Date of death precedes date(s) of service
62	Date of service not within valid enrollment
63	Date of service in ineligible period
71	Patient birth date does not match
72	Invalid/missing subscriber ID
73	Invalid/missing subscriber name
75	Subscriber not found
76	Duplicate subscriber ID
78	Subscriber found, patient not found

MSG — Free-Form Message

Additional text explanation:

MSG*CONTACT MEMBER SERVICES FOR ADDITIONAL INFORMATION~

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EDI Paisan Features

Viewing

• Eligibility status at-a-glance — Active/inactive clearly indicated
• Member details — Name, ID, DOB, gender
• Plan information — Name, group number, policy number
• Coverage dates — Effective and termination dates
• Benefit breakdown — Organized by benefit type and service

Eligibility Summary (Pro)

EDI Paisan extracts and summarizes:

Category	What's Shown
Status	Active/Inactive with status code
Deductibles	Individual and family, met vs. remaining
Out-of-Pocket Max	Individual and family, met vs. remaining
Copays	By service type (office visit, specialist, etc.)
Coinsurance	Percentage by service type
Covered Services	List of covered service types
Exclusions	Services explicitly not covered
Rejections	Any AAA errors with descriptions

Benefit Display

For each EB segment, EDI Paisan shows:

• Human-readable benefit type
• Coverage level (individual/family)
• Service type description
• Monetary amounts or percentages
• Time period (annual, per visit, lifetime)
• In-network indicator
• Authorization requirements

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Example 271 Structure

ISA*00*          *00*          *ZZ*BCBS           *ZZ*PROVIDER       *240115*1000*^*00501*000000001*0*P*:~
GS*HB*BCBS*PROVIDER*20240115*1000*1*X*005010X279A1~
ST*271*0001*005010X279A1~
BHT*0022*11*BATCH001*20240115*1000~
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*2*TRACE001*9BCBS~
NM1*IL*1*SMITH*JOHN****MI*MEM123456~
N3*200 OAK AVENUE~
N4*SOMEWHERE*NY*12346~
DMG*D8*19850315*M~
DTP*291*D8*20240101~
DTP*292*D8*20241231~
EB*1**30**PREMIER PPO~
EB*C*IND*30***23*500~
EB*C*FAM*30***23*1500~
EB*C*IND*30***29*250~
MSG*INDIVIDUAL DEDUCTIBLE MET TO DATE: $250~
EB*G*IND*30***23*3000~
EB*G*FAM*30***23*6000~
EB*B*IND*98****25~
MSG*OFFICE VISIT COPAY~
EB*A*IND*30****20~
MSG*AFTER DEDUCTIBLE IS MET~
EB*1**35**DELTA DENTAL PPO~
DTP*291*D8*20240101~
EB*C*IND*35***23*50~
EB*F*IND*35***23**1000~
MSG*DENTAL MAXIMUM $1000 PER YEAR~
SE*32*0001~
GE*1*1~
IEA*1*000000001~

This example shows:

• Active coverage under Premier PPO
• $500 individual deductible ($250 met, $250 remaining)
• $3,000 individual out-of-pocket max
• $25 office visit copay
• 20% coinsurance after deductible
• Separate dental coverage with $1,000 annual maximum

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Reading Eligibility Like a Pro

Step 1: Check Status First

Look for EB segments with EB01 = 1-5 (active) or 6-8 (inactive).

Step 2: Find Plan Info

EB segments with EB01 = 1 and EB05 populated contain the plan name.

Step 3: Check Deductibles (EB01 = C)

• Look for EB06 = 23 (calendar year) or 29 (remaining)
• Remaining deductible = amount left for patient to pay
• Check both IND and FAM levels

Step 4: Check Out-of-Pocket Max (EB01 = G)

Same logic as deductibles. This is the patient's maximum responsibility.

Step 5: Check Cost-Sharing

• EB01 = B with EB07 = dollar amount = copay
• EB01 = A with EB08 = percentage = coinsurance

Step 6: Note Exclusions and Limitations

• EB01 = E = explicitly excluded services
• EB01 = F = limitations (visit counts, dollar limits)

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Common Issues

Multiple EB Segments

A 271 may have dozens of EB segments. They're not duplicates — each represents a different:

• Service type
• Coverage level (individual vs. family)
• Time period
• Network status

Missing Information

Payers aren't required to return all benefit information. If something is missing:

• It may require a more specific inquiry (different service type code)
• Or the payer simply doesn't support that data electronically

Rejection Handling

If you receive AAA segments instead of (or alongside) EB segments:

1. Read the reject reason code
2. Correct the issue in your 270
3. Resubmit the inquiry

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Related Documentation

• 270 Eligibility Inquiry — Sending the request
• Eligibility Feature Guide — Using eligibility summaries
• Benefit Code Reference — Complete code lookups