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Back  RFI # 634: 270 / 271 Transactions

Formal vs. Informal Help Informal Formal

Submitter

Jennifer McMullin

Description

Could provider use a 270/271 transactions to request not only eligibility, but a specific service approval from a health plan?

Could a health plan use these transactions as part of a process to reserve benefits when the provider submits a request for eligibility through IVR, Web Portal or a Clearing House?

Also, could the provider submit a reversal of the request?

Response

The appropriate transaction for approval of a specific service is the X12N 004010X094 278 Health Care Services Review - Request for Review and Response and associated Addenda 004010X094A1.
The appropriate transaction for the reservation of a service/benefit is the X12N 004010X092 270/271 Health Care Eligibility Benefit Inquiry and Response and associated Addenda 004010X092A1. The 270/271 has a function called "Medical Service Reservation" which is triggered by sending a value of "RU" (Medical Service Reservation) in BHT06 of the 270. There also is a function to reverse (cancel) a previous reservation by sending a subsequent 270 transaction with BHT02="01" (Cancellation).
If a service/benefit does not require prior approval, only a reservation of a service, the 278 transaction is not needed. In the event that the patient has exhausted the number of services allotted to them, the 271 response can respond that the patient has exceeded their allocation for the service and it is non-covered.

Recommendation

Continued response:
Payers who choose to implement the Medical Service Reservation functionality available in the 270/271 must ensure the accuracy of the information being returned in the 271 as to whether there were sufficient services remaining to accept the reservation and if there were not must indicate that the services have been exceeded using.

EB01 = I (Non-Covered)
EB06 = 30 (Exceeded)
and any other information from the request (such as the service type code or procedure code) that was used to create the response.

Note:
The Medical Service Reservations functionality has moved from the 270/271 transaction to the 278 transaction in the 005010 version of the Implementation Guides. When future versions are adopted for use under HIPAA, payers and providers would need to use the 278 for the Medical Service Reservations function.
Submission 2/28/2008
Status Date 6/17/2008
Status F - Final
Primary References
Document 004010X092
SectionN/A
PageN/A
Set IDN/A