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 the National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D.0. These standards apply to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid. For more information, see the official ASC X12 website.

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, and coinsurance
• Coverage information for specific service types
• Provide secure access to eligibility information over the Internet
• View the eligibility and benefits operating rules