Why patient access matters
Many downstream claim problems begin with incorrect patient, subscriber or coverage information. Patient access workflows reduce preventable rework by confirming the right patient, plan, provider relationship and benefit information before services are billed.
Core information to verify
- Patient name, date of birth and contact information.
- Subscriber/member name, relationship and member ID.
- Payer and plan/product.
- Coverage effective dates.
- In-network or out-of-network status when relevant.
- Copay, deductible, coinsurance and applicable benefit details.
- Referral or prior authorization requirements.
270/271 eligibility and benefits
The HIPAA eligibility inquiry/response transaction uses a 270 request and a 271 response. CMS eligibility operating rules require health plans to support real-time access to information such as coverage and patient financial responsibility for supported service types.
270
An eligibility and benefit inquiry sent to the health plan or intermediary.
271
The eligibility and benefit response returned for the inquiry.
Verification result
A snapshot of available payer information that still must be interpreted for the planned service.
Quick knowledge check
What does a 271 provide?
An eligibility and benefits response to a 270 inquiry.
Does active coverage guarantee claim payment?
No. Payment depends on the final adjudication and applicable payer rules.
Why verify near the date of service?
Coverage and benefit details can change, so current verification reduces avoidable front-end errors.
Create a free learner account to mark lessons complete and track Module 7 on your dashboard.
Create Free Account