Eligibility first: what a 271 actually tells you

2 min read

The eligibility inquiry and response, 270 and 271, are cheap, fast, and the highest-yield step in the whole process. A meaningful share of what practices experience as authorization problems are eligibility problems that were never checked.

#What you get back

Whether coverage is active: And on what dates. A patient active today may not be active on a service date six weeks out.
The plan, not just the payer: Which product the member is enrolled in. This is what determines the requirement list, and it is the field practices most often fail to capture.
Cost sharing: Copay, coinsurance, deductible and how much of it is met. Useful for the financial conversation and sometimes for deciding whether a service is worth pursuing at all.
Service type detail: Benefits broken out by service type code, so you can ask specifically about the category you care about rather than reading a general response.
Sometimes authorization requirements: Some payers return whether authorization is required for a service type. Where it exists this is the most current answer available, because it comes from the plan at the moment you asked. Coverage is inconsistent and it is rarely complete enough to rely on alone.

Active is not the same as covered for this

A 271 saying coverage is active tells you the member has a policy. It does not tell you the policy covers the service you are about to authorize. Benefit exclusions, waiting periods and plan-specific carve-outs live below that headline and are a frequent source of an approved authorization that still does not pay.

#When to run it

At scheduling
This is where lead time is created. Everything downstream depends on knowing the plan early.
When anything changes
A new card, a reported job change, a marriage. Each is a coverage event.
Close to the service date
Cheap insurance against coverage that lapsed in between. This single check prevents a category of write-off that is otherwise discovered at billing.

#Coordination of benefits

When a patient has more than one policy, order matters. The primary plan is billed first, and an authorization obtained from the secondary plan does not substitute. The eligibility response may indicate other coverage, but it is frequently incomplete, and patients routinely forget policies they are on.

For a service expensive enough to authorize, asking the patient directly whether they have any other coverage is worth the thirty seconds. It is a question people answer accurately when asked and never volunteer.