Introduction > About HIPAA Eligibility Responder

What is HIPAA Eligibility Responder?

The HIPAA Eligibility Responder application is a fantastic tool for healthcare service providers to establish patient eligibility. It was designed to parse out a 270 eligibility request file and allow the manual entry of eligibility response information. It can then use the request information to construct a 271 response transaction, ready to be returned to the inquiring provider. The HIPAA Eligibility Responder application is a low-cost solution designed to bring a payer or any other covered entity into compliance with the HIPAA Act.

The HIPAA Eligibility Responder can work together with any SQL-compliant database. Eligibility requests can be exported into the database and a process to look up member benefit status is available. The implementer will have to populate the eligible benefits tables from their database.

In the past, this was handled by telephone operators or voice response systems with fax-back options. Doctors need to know by the time they see a patient if they are covered, if co-payments need to be collected, and if a certain diagnosis is included. Since HIPAA introduced the X12 270 and 271 pair of EDI transaction sets to transmit eligibility data, more providers and payers are implementing this process, especially with the Affordable Care Act (ACA or Obamacare). This law also mandates payers to implement a real-time response solution for common provider requests.

HIPAA Eligibility Responder manages the complex tasks of answering 270 electronic eligibility requests by automatically sending 271 EDI files in real-time.

Background

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was the first attempt to create nationwide rules to enact administrative simplification into the provider-payer relationship. It intended to lower the cost of doing business for payers and facilitate communication between payers and providers. For this, Electronic Data Interchange (EDI) was employed. The government, through its National Bureau of Standards, is the guardian of the rules and details of the different EDI transactions for each involved industry. See more on EDI in About EDI.

The 270 EDI transaction is the request for eligibility information. Typically, a provider would take patient information and compose the request message. He would then expect a 271 EDI response message. EDI transactions that begin with a "2" are real-time transactions, such as the 270/271 and the 276/277. That means responses are expected within 20 seconds, unlike in the past, when a response was allowed by 7 am the following day.

The original HIPAA Act described EDI 270 as the transaction set for the eligibility request and EDI 271 for the eligibility response. However, it did not specify the necessary infrastructure, such as transport protocol. This changed with the Affordable Care Act, which adopted the rules developed by the Coalition for Affordable Quality Healthcare (CAQH), a consortium of healthcare industry providers and insurers. They devised and established mechanisms to transfer eligibility information in real-time between two computers, which greatly enhanced the efficiency of establishing insurance coverage for a patient.

What features are available in HIPAA Eligibility Responder?

Here is a list of the features of the HIPAA Eligibility Responder:

oAccepts 270 EDI files, versions 4010 and 5010,

oParses the entire file and lists individual requests,

oAllows answering requests sequentially or randomly from the listing,

oAllows editable code sets to modify according to the company's needs and delete the codes that do not apply,

oAllows to configure specific and multiple benefits, utilizing the full 271 transaction set scope,

oProvides a "Quick Response" option to return the HIPAA minimum information that the 271 transaction allows,

oAllows for request rejection on multiple levels according to the implementation guide,

oAfter an eligibility status assignment, the application will create one 271 file that can be returned to the sender,

oExports information to any ODBC and SQL-compatible database,

oRetrieves eligibility information and creates 271 eligibility response transactions, and

oPart of a CORE Phase I and II compliant solution with the HIPAA RealTime Server.