CMS offers an X12 270/271 Eligibility System (HETS 270/271)
The HIPAA Eligibility Transaction System (HETS) is intended to allow the release of eligibility data to Medicare Providers, Suppliers, or their authorized billing agents for the purpose of preparing an accurate Medicare claim, determining Beneficiary liability or determining eligibility for specific services.
The Eligibility Benefit Inquiry application is developed using the CMS HIPAA Eligibility Transaction System (HETS) and it allows real-time access to patient Medicare Eligibility information, including coverage dates, benefit ceilings, co-pays, deductible and more.
One of the most common reasons for claim rejection or denial is ineligibility.
Rather than putting reimbursement at risk after a patient encounter, you can use our real-time eligibility solutions to determine patient insurance eligibility prior to rendering service.
With this web application, you’ll be able to:
- Receive real-time access to critical patient and insurance information, including coverage dates, benefit ceilings, co-pays and more
- Reduce costly rejections and denials by checking eligibility before patients are seen
- Increase profitability – reduce costly write-offs
- Improve productivity – eliminate manual eligibility verification and one website to access multiple payers
- Increase cash collections – obtain up-to-date co-pay, co-insurance and deductible information
The purpose of generating a 270 Inquiry is to allow providers to determine if, and what, benefits and coverage for a specific period of time. The following information is required to run an eligibility inquiry:
- Patient’s Medicare Number (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI])
- Patient's Full First and Last Name
- Patient’s Date of Birth
- Date of Service: 12 Months Prior & 4 Months after Today
- Additional Service & Coverage Types are Available upon Request
The 271 response contains information such as eligibility, eligibility dates, copays, coinsurance, deductibles, out of pocket maximums, visit limits, benefit limits, and more. The 271 document typically includes the followings:
- Details of the sender of the inquiry (name and contact information of the information receiver)
- Name of the recipient of the inquiry (the information source)
- Details of the plan subscriber about to the inquiry is referring
- Description of eligibility or benefit information requested