Claims and Eligibility

EDI Eligibility/Benefit Inquiry and Response (270/271)

When do providers use this?

270

To inquire about the health care eligibility and benefits associated with a CalOptima member.

The 270 typically includes:

  • 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 CalOptima member, related to the inquiry
  • Description of eligibility or benefit information requested

Use the 270 transaction with the EDI 271 transaction. The 271 is the Health Care Eligibility/Benefit Response used to transmit the information requested in a 270.

271

CalOptima sends the 271 transaction in response to the 270 inquiry. Its intention is not to provide a complete representation of all benefits, but rather to address the status of eligibility, benefit information and member financial responsibility, when applicable.

The 271 typically includes:

  • 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 CalOptima member, related to the inquiry
  • Description of eligibility or benefit information requested

The 271 response should not be interpreted as a guarantee of payment. Payment of benefits remains subject to all health plan benefit terms, limits, conditions, exclusions and the member’s eligibility at the time providers render services.

What are the benefits?

Electronic eligibility verification may have these benefits:

  • Reduced collection and billing costs
  • Decreased bad debt
  • Improved cash flow
  • Increased productivity and efficiency
  • Fewer rejected claims
  • Less time spent on manual, administrative tasks
  • Expedited reimbursement

Providers can perform eligibility (270/271) transactions in real-time mode, based on connectivity method.

Getting started

For an overview of how this process works and the user agreements — that may be required prior to activation — visit the Office Ally website for Eligibility/Benefit request.

If you have questions about real-time transactions, contact the Office Ally Customer Service department at 360-975-7000.

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