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The HIPAA Eligibility Responder

Software Solutions for the 270/271 HIPAA Transaction Sets.

The 270/271 pair of HIPAA transaction sets is designed to convey eligibility information between a provider's office and an insurance company. Before a provider treats a patient in his office or in the hospital the eligibility for health care insurance can be established. The provider creates a 270 transaction set, which contains basic demographic information on the patient and insured plus it can list the procedures and types of service that the provider plans to perform. This 270 request for eligibility information is then transmitted to the insurance company where the request is answered with a 271 transaction. Transaction sets that begin with the number '2' are normally regarded as real time transactions, which means that the response should be returned within a minute or within 20 sec as required by CORE. This requirement has been waived for HIPAA and a response within 24 hours is acceptable for now, though this will change and CORE compliance is part of the Affordable Care Act (ACA or ObamaCare).

The HIPAA Eligibility Responder is for organizations that need to respond to 270 eligibility requests. This software is designed to enable HIPAA compliance in regard to the 270/271 transaction sets without a big investment. The software parses the information that is contained in an X12 270 EDI Eligibility Request file. There are two modes to respond, manually and automatically. The manual response mode is aimed at organizations that do not expect a large volume of electronic eligibility requests but want to be in compliance with federal regulations while the database interface automates the process of generating electronic eligibility responses and can handle large volumes of requests without human intervention.

For automatic processing, the HIPAA Eligibility Responder exports the EDI data into any ODBC/SQL compliant database, such as Microsoft SQL server, Oracle, and MySQL. A data table structure is provided into which the eligibility data for the whole membership can be stored. A request transaction that comes in is then matched with the available eligibility information so that the software creates the 271 automatically. It will be the responsibility of the user of this software to supply this interface with our data tables and we provide assistance and consulting services if needed to make sure you have a successful implementation.

We are currently developing and testing a CORE II compliant SOAP server that interacts with the HIPAA Eligibility Responder to provider real-time 271 responses. We are committed to the SOAP technology because is the most effective way for computers of different types to communicate in real-time. Please contact us for more information or if you are interested to be an early adopter.

 The HIPAA Eligibility Responder has the optional EDI Exchange module, that allows you to further automate the processing by adding HIPAA compliance checks, trading partner management, FTP transport and encryption to the process.

Download a 15-day trial version of the HIPAA Eligibility Responder.

View the detailed help documentation for HIPAA Eligibility Responder. PDF Icon- Acrobat PDF

The HIPAA Eligibility Responder will enable you to:

  • Display the eligibility request information on screen.
  • EDI code sets are translated into their descriptions to show the transactions clearly and understandably.
  • Choose from drop down menus the appropriate code sets and avoid data entry mistakes.
  • Return a simple answer, the HIPAA minimum requirement or add the complete spectrum of information that the 277 transaction set allows.
  • Package multiple eligibility responses into one file.
  • Set a default status response that gets filled in, if you don't create a specific answer like "Claim not Found" or "No further information available".
  • Edit the code sets, so you will have to choose only from a subset of the hundreds of codes that HIPAA provides.
  • Export the request data to any ODBC/SQL compliant database.
  • Create the 271 response file if eligibility data is provided through a data interface.