271 Benefit Response

After you send a successful eligibility check, the payer sends back a 271 Eligibility Benefit Response containing the patient’s benefits information, including coverage status, co-pays, and deductibles.

Stedi transforms the 271 response from the original x12 EDI into JSON, making it easier to read, understand, and ingest into your system.

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Coverage period

Most commercial payers only return information for the current calendar year, except for Medicare and Medicaid coverage. When the patient has Medicare or Medicaid, the start date is typically when the individual reached age of 65, but it can be earlier if the patient has certain medical conditions or disabilities.

"planInformation": {
        "groupNumber": "12341234",
        "groupDescription": "Company Name",
        "priorIdNumber": "1234567890"
    },
    "planDateInformation": {
        "planBegin": "20240101",
        "planEnd": "20241231",
        "eligibilityBegin": "20240102"
    }

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In and out-of-network coverage

The response provides information about the patient’s general in and out-of-network coverage based on the service type codes and dates provided in the request. It does not confirm whether a particular provider is in or out of network for that patient.

The inPlanNetworkIndicatorCode field specifies whether the benefits are considered in or out of the patient’s network - Y for yes or N for No. A U indicates it is unknown whether the benefits are in or out of network.

The example benefit response object below shows the patient’s out-of-network deductible for the calendar year, which is $7500. The inPlanNetworkIndicatorCode is N, indicating that the deductible is out-of-network:

{
  "code": "C",
  "name": "Deductible",
  "coverageLevelCode": "IND",
  "coverageLevel": "Individual",
  "serviceTypeCodes": ["30"],
  "serviceTypes": ["Health Benefit Plan Coverage"],
  "timeQualifierCode": "23",
  "timeQualifier": "Calendar Year",
  "benefitAmount": "7500",
  "inPlanNetworkIndicatorCode": "N",
  "inPlanNetworkIndicator": "No"
}

​

Copays, co-insurance, and deductibles

Depending on the health plan, the response may include information about the patient’s copays, co-insurance, and deductibles. Objects containing codes A, B, C, G, J, or Y describe these types of patient responsibilities.

The following example shows a benefit response object for a patient’s co-payment for in-office visits. This copayment is $20 and is considered in-network, as indicated by the Y in the inPlanNetworkIndicatorCode field:

{
  "code": "B",
  "name": "Co-Payment",
  "coverageLevelCode": "IND",
  "coverageLevel": "Individual",
  "serviceTypeCodes": ["A4", "A6", "22"],
  "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
  "timeQualifierCode": "27",
  "timeQualifier": "Visit",
  "benefitAmount": "20",
  "authOrCertIndicator": "N",
  "inPlanNetworkIndicatorCode": "Y",
  "inPlanNetworkIndicator": "Yes",
  "eligibilityAdditionalInformation": {
    "codeListQualifierCode": "Mutually Defined",
    "industryCode": "Office"
  },
  "eligibilityAdditionalInformationList": [
    {
      "codeListQualifierCode": "Mutually Defined",
      "industryCode": "Office"
    }
  ]
}