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Health Plan Eligibility Benefit Inquiry and Response

Under HIPAA, HHS adopted standards for electronic transactions, including the health plan eligibility benefit inquiry and response.

  • The eligibility/benefit inquiry transaction is used to obtain information about a benefit plan for an enrollee, including information on eligibility and coverage under the health plan. This inquiry can be sent from a health care provider to a health plan, or from one health plan to another.
  • The eligibility benefit/response transaction is used by health plans to respond to a health care provider’s (or another health plan’s) inquiry about an enrollee’s eligibility and coverage. 

HIPAA Adopted Standards

In January 2009, HHS adopted Version 5010 of the ASC X12N 270/271 for health plan eligibility benefit inquiry and response.

For pharmacy-related eligibility benefit inquiry and response transactions, HHS adopted NCPDP Telecommunications Standard Version D.0. 

This standard applies to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.

Operating Rules

As of January 1, 2013, HIPAA-covered entities are required to comply with federally mandated operating rules for eligibility for a health plan.

Eligibility operating rules require health plans to respond in real time to providers’ eligibility questions with a patient’s financial information, including:

  • Deductibles, co-pays, coinsurance, in/out of network variances
  • Coverage information for specific service types
  • Provide secure access to eligibility information over the Internet

View Phase I Operating Rules and Phase II Operating Rules for eligibility of a health plan. 

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