The first and foremost dominant element in the healthcare industry is patient eligibility. All insurance companies determine the amount of coverage along with level of benefits through their patient’s eligibility. Additionally, even the amount of payment for these services is based on patient eligibility. Insurance companies also face the dilemma of communicating patient eligibility to healthcare providers and the timeline associated with it.
Until recently, patient eligibility was determined through a phone conversation whereby a series of “Yes/No” questions were asked. Consequently, these conversations were often limited in providing greater coverage and benefits detail to the patient and were merely a tool for the insurance companies to determine the level of eligibility.
However, the adoption of the Healthcare Eligibility, Coverage and Benefit Inquiry (270) and Response (271) transactions allowed for a Provider of Service to obtain in-depth details of coverage, benefit, and eligibility from the patient’s Insurance Company. The 270 Request is initiated by the Provider of Service and contains patient data in which eligibility detail is being requested from the Insurance Companies. This allows Providers of Service an automated capability of requesting detailed eligibility information which also has the added advantage of being HIPAA compliant. Indirectly, the 270 Request and the proper use of the 271 Response information reduce possible 837 claim rejections and 835 remittance advice denials for ‘non-eligible member’ or ‘non-eligible service’. Properly verified eligibility ensures that claim processing and accurate benefit provisions are received.
As the 270 Inquiry and 271 Response also leverages system automation, there is also a significant reduction in outdated manual processes. The overall collection and billing costs are also minimized, due to fewer rejected claims and expedited reimbursement. Overall, the entire process enjoys greater productivity and efficiency, along with the availability of both participating and non-participating health care professionals to reap the benefits.
It is no surprise then the eligibility 270 Request and 271 Response is the third most utilized transaction in the healthcare industry (after Claims Submission and Remittance Advice Transactions).