Eligibility Summaries

EDI Paisan transforms complex 270/271 eligibility files into clear, readable summaries. Understand patient coverage at a glance — deductibles, copays, coinsurance, and what's covered.

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What Are Eligibility Files?

Eligibility transactions verify patient insurance coverage:

Transaction	Direction	Purpose
270	Provider → Payer	"Is this patient covered for this service?"
271	Payer → Provider	"Here's their coverage details..."

The 270 is the question. The 271 is the answer.

Why They Matter

Before scheduling a procedure or providing services, you need to know:

• Is the patient's coverage active?
• What are their deductibles and out-of-pocket limits?
• Does the service require prior authorization?
• Is there a copay or coinsurance?
• Is there a referral requirement?

The 271 answers all of these — if you can read it.

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The Problem with Raw 271s

A raw 271 looks like this:

EB*C*IND*30*HM*PREMIER PPO*23*1500***Y~
EB*G*IND*30***6000~
EB*B*IND*98****30~
EB*A*IND*30****20~

Quick — what's the copay for a specialist visit?

This is where EDI Paisan helps.

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EDI Paisan's Eligibility View

EDI Paisan parses 271 files and presents coverage information in clear, organized sections.

Coverage Status

At-a-glance confirmation:

Field	Value
Status	✅ Active
Plan Name	Premier PPO
Group Number	GRP123456
Policy Number	POL789012
Effective Date	01/01/2024

Patient Information

Field	Value
Subscriber	SMITH, JOHN
Member ID	MEM123456789
Date of Birth	03/15/1985
Relationship	Self

Benefit Summary

Clean breakdown of cost-sharing:

Benefit Type	Individual	Family
Deductible	$1,500	$3,000
Remaining	$850	$1,700
Out-of-Pocket Max	$6,000	$12,000
OOP Remaining	$4,200	$9,500

Copays & Coinsurance

Service	In-Network	Out-of-Network
Primary Care	$30 copay	40% after deductible
Specialist	$50 copay	50% after deductible
Urgent Care	$75 copay	50% after deductible
ER	$250 copay	$250 copay
Generic Rx	$10 copay	Not covered
Brand Rx	$40 copay	Not covered

Authorization Requirements

Service Type	Auth Required	Notes
Outpatient Surgery	✅ Yes	Contact plan 5 days prior
Imaging (CT/MRI)	✅ Yes	Requires referral
Physical Therapy	✅ Yes	20 visits/year limit
Lab Work	❌ No	—
Office Visits	❌ No	—

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Understanding Coverage Details

Coverage Levels

The 271 reports benefits at different levels:

Level	Code	Meaning
Individual	IND	Applies to one person
Family	FAM	Applies to entire family
Employee Only	EMP	Employee coverage only
Employee + Spouse	ESP	Employee and spouse
Employee + Children	ECH	Employee and dependents

In-Network vs Out-of-Network

Most plans distinguish between:

Benefit	In-Network	Out-of-Network
Deductible	Often lower	Usually higher
Coinsurance	10-20%	30-50%
Out-of-Pocket Max	Combined or separate	May be unlimited
Balance Billing	Not allowed	Patient liable

EDI Paisan clearly separates in-network and out-of-network benefits when the 271 reports them.

Time Periods

Benefits may apply to different periods:

Code	Period
23	Calendar Year
24	Plan Year
25	Contract
26	Episode of Illness
27	Visit
29	Remaining

"Remaining" values show what's left of annual limits.

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Common Eligibility Scenarios

Active Coverage Confirmed

Status: ✅ Active
Plan: BlueCross PPO
Deductible Met: $1,200 of $1,500 (80%)

Interpretation: Patient has active coverage. Most of their deductible is met.

Coverage Inactive

Status: ❌ Inactive
Termination Date: 12/31/2023
Reason: Non-payment

Interpretation: Coverage ended. Contact patient about payment or new coverage.

Pending Investigation

Status: ⚠️ Pending Investigation
Message: Eligibility under review. Contact payer for status.

Interpretation: Payer is verifying coverage. Wait or call payer directly.

Service Not Covered

Service: Cosmetic Procedure (CPT 15780)
Status: ❌ Not Covered
Reason: Plan exclusion for cosmetic services

Interpretation: This service is excluded from the patient's plan.

Prior Authorization Required

Service: MRI, Brain (CPT 70553)
Status: ✅ Covered
⚠️ Prior Authorization Required
Phone: 1-800-555-AUTH

Interpretation: Service is covered but needs pre-approval.

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PDF Reports

Pro tier users can generate printable eligibility summaries. Reports are rendered as formatted HTML and can be saved as PDF using your browser's Print function (Ctrl+P / Cmd+P).

What's Included

• Patient and subscriber information
• Coverage status and dates
• Benefit summary table
• Copay and coinsurance details
• Authorization requirements
• Important notes and limitations

Use Cases

• Patient communication — Give patients a readable summary
• Pre-service verification — Document coverage before procedures
• Records — File with patient chart

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Tips for Reading Eligibility

Check the Date

Eligibility responses are point-in-time. A 271 from last week may not reflect today's coverage.

Verify the Service Type

Benefits vary by service. A 271 for "all services" gives general info. For specific procedures, request eligibility for that service type code.

Watch for Limitations

Look for:

• Visit limits (e.g., "20 PT visits per year")
• Dollar maximums
• Waiting periods
• Pre-existing condition exclusions

Note Authorization Requirements

Even if a service is covered, it may require prior auth. Missing this step = denial.

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Tier Requirements

Feature	Free	Pro	Enterprise
View parsed 270/271	✅	✅	✅
Benefit summary view	✅	✅	✅
Export PDF summary	❌	✅	✅
Batch eligibility processing	❌	❌	✅

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Related Documentation

• 270 Eligibility Inquiry Reference — Understanding inquiry files
• 271 Eligibility Response Reference — Technical segment details
• Pro Tier — PDF export and more