Getting a medical bill for a service you thought insurance would handle is frustrating — whether it was a routine checkup, a lab test, or a specialist visit. The issue often comes down to eligibility: The provider didn’t confirm coverage with the insurer before providing treatment.
Unfortunately, it happens more frequently than it should. But thanks to the EDI 270, it happens far less often than it otherwise would.
In this guide, we’ll highlight how healthcare providers use this Electronic Data Interchange (EDI) document to verify a patient’s insurance coverage. We’ll also explain the specifics of the EDI 270’s structure and how it helps save time, minimize errors, and protect patient privacy.
What’s the EDI 270?
The EDI 270 is a standard electronic transaction that healthcare providers in the U.S. use to inquire about a patient’s insurance coverage and eligibility. It’s one of hundreds of formats defined by ASC X12, which oversees EDI standards in North America.
Hospitals, clinics, and doctor’s offices use the EDI 270 to confirm whether a patient’s healthcare plan covers a service — like surgery, physical therapy, or a routine checkup — before proceeding. The inquiry includes key subscriber details, such as ID numbers, coverage dates, and specifics regarding the healthcare service the provider plans to perform.
EDI 270 vs. EDI 271 Transactions
The EDI 270 doesn’t work alone — an EDI 271 response always follows it. After receiving a 270 inquiry, the insurance provider sends back a 271 document with the information requested, including the patient’s benefit status, applicable coverage details, and any service limitations. Together, the two transactions create a fast, reliable exchange between providers and payers, helping avoid billing issues, denied claims, or delays in care.
The EDI 270 Specification, Format, and Elements
The EDI 270 follows strict rules under the ANSI X12 standard, allowing healthcare providers and insurance carriers to exchange eligibility inquiries across different systems. By using a shared structure, healthcare organizations and insurance carriers can send and receive requests electronically, even if they use different platforms or formats internally.
EDI 270/271 Example
ISA*00* *00* *ZZ*SENDERID *ZZ*RECEIVERID *210101*1230*^*00501*000000001*0*T*:~
GS*HS*SENDERID*RECEIVERID*20210101*1230*1*X*005010X279A1~
ST*270*0001*005010X279A1~
BHT*0022*13*123456*20210101*1230~
NM1*PR*2*INSURANCE COMPANY*****PI*12345~
NM1*1P*2*HOSPITAL NAME*****XX*9876543210~
NM1*IL*1*DOE*JOHN****MI*123456789~
SE*9*0001~
GE*1*1~
IEA*1*000000001~
Key Data Elements and Segments
EDI 270 files contain many individual segments, each with specific data elements. These elements provide the information an insurance provider needs to evaluate the 270’s inquiry — who’s making the request (the healthcare provider), who it’s about (the patient), what healthcare service is in question, and when it will tentatively happen. Together, these segments give the insurance provider enough context to respond with accurate eligibility and coverage details in a 271.
Using the above example, here’s a breakdown of the key segments you’ll typically find in an EDI 270 transaction set:
ISA (Interchange Control)
The Interchange Control header begins the EDI file and includes routing information like sender and receiver IDs, the file creation date and time, and a version number that helps systems read the file correctly. This segment makes sure both parties are using the same format to process the transaction.
GS (Functional Group)
The Functional Group header opens a batch of related transaction sets and identifies their purpose — in this case, healthcare eligibility inquiries. It includes sender and receiver codes, date and time stamps, and a group control number to organize and track the set.
ST (Transaction Set)
The Transaction Set header marks the beginning of a specific EDI 270 transaction. It signals to the receiving system that what follows is an eligibility or benefit inquiry and includes a transaction set control number for tracking.
BHT (Beginning of Hierarchical Transaction)
The Beginning of Hierarchical Transaction segment contains metadata about the request. It identifies the purpose of the inquiry, assigns a control number, and includes the transaction’s creation date and time. This helps both the provider and payer track the request throughout the exchange.
NM1 (Individual or Organization Name)
The Individual or Organization Name segments identify the entities involved in the transaction. NM1*PR refers to the insurance provider (payer) receiving the inquiry. NM1*1P identifies the healthcare provider submitting the request, such as a hospital, clinic, or physician’s office. NM1*IL contains subscriber details, including the patient’s full name, subscriber ID, and relationship to the primary policyholder.
DTP (Date or Time Period)
The Date or Time Period segment specifies the service date or date range being checked. This gives the payer a timeframe to evaluate when determining the patient’s coverage eligibility.
EQ
The Eligibility or Benefit Inquiry segment identifies the type of service being requested. It includes service type codes, like those for inpatient hospital care, diagnostic lab services, or physical therapy, so the insurance provider can return the relevant benefit details in the 271 response.
REF (Reference Identification)
The Reference Identification segment includes unique identifiers, such as a trace number or control number. These references help both the sender and receiver link the 270 inquiry to its corresponding 271 response.
SE (Transaction Set)
The Transaction Set trailer marks the end of the individual EDI 270 transaction. It includes a segment count that helps validate the integrity of that specific inquiry and ensures the transaction is complete.
GE (Functional Group)
The Functional Group trailer closes the group of transaction sets initiated by the GS segment. It includes the group control number and confirms the number of transactions in the group.
IEA (Interchange Control)
The Interchange Control trailer wraps up the entire EDI file and references the opening ISA segment. It confirms that all grouped transactions are present and that the sender's EDI system transmitted the full interchange with no issues.
Benefits of the EDI 270
The EDI 270 allows healthcare providers to check a patient’s insurance coverage before delivering care much faster and more accurately than traditional paper methods. Instead of calling payers or faxing forms, providers can send an electronic request and get a response in minutes. That speed helps clinics, hospitals, and diagnostic labs reduce delays, avoid billing issues, and focus more on patient care.
Below are a few noteworthy benefits the EDI 270 brings to the modern healthcare system:
Faster, More Reliable Data Exchange
Because the EDI 270 uses the X12 EDI format, healthcare providers can electronically inquire about a patient’s coverage and receive an acknowledgment from the payer in minutes. This replaces phone calls and paper forms, which are slower and more prone to errors. By cutting out manual steps, the 270 makes it easier to verify a patient’s eligibility before they ever reach the exam room.
Fewer Errors
Manual data entry leaves room for mistakes, whether it’s a mistyped insurance ID or a missed coverage detail. EDI 270 transactions help prevent those issues by electronically transmitting data between systems using structured segments like NM1 (name) and DTP (date). When routed through secure, cloud-based platforms that update in real time, EDI transactions help maintain accurate eligibility records and reduce downstream billing problems, like denied claims or bad debt.
Improved HIPAA Compliance
In the United States, strict HIPAA regulations require healthcare providers to protect patients’ privacy. EDI 270 files are central to that because they use secure formats to keep confidential data safe from unauthorized access. And they reduce the chance of sending files to the wrong party, since EDI systems verify payer and provider IDs before transmission, and confirmation responses — like an EDI 999 or an EDI 271 — flag issues right away.
Replacing traditional inquiry methods with EDI transactions also helps maintain accurate records, making it easier to verify compliance during HIPAA or internal data security audits.
Talk to an EDI Expert
Compliant EDI 270/271 transactions are just one aspect of healthcare administration, but they're among the most important. Fortunately, you don’t have to go it alone. The right EDI partner will help ensure you meet HIPAA regulations and find practical ways to simplify administrative tasks.
Ready to simplify your eligibility verification process with a modern EDI solution? Connect with an EDI expert to get started.