Is a generic request for eligibility, as described in the 270/271 Implementation Guide, considered an acceptable minimum for HIPAA compliance, or must a covered entity be able to respond to all three kinds of requests described in the final rule text at Section 162.1201?
Section 162.1201 of the final rule states: "The eligibility for a health plan transaction is the transmission of either of the following:
(a) An inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee:
- Eligibility to receive health care under the health plan.
- Coverage of health care under the health plan.
- Benefits associated with the benefit plan.
(b) A response from a health plan to a health care provider's (or another health plan's) inquiry described in paragraph(a) of this section."
Section 1.3.7 of the 270/271 Implementation Guide addresses the minimum requirements for HIPAA compliance. This section states that the information source (the entity answering the questions being asked in a 270 eligibility or benefit inquiry) must support a generic request for eligibility. This is equivalent to asking the question, "Is this patient eligible today?"
The information source must at least be able to respond with the minimum compliant response ("Yes, the patient is eligible today" or "No, the patient is not eligible today") and may not reject the transaction merely because the responder cannot process an explicit request. The information source for the 271 is not required to generate an explicit response to an explicit request if its system is not capable of handling such requests. The information source for the 271 must return any information supplied in the 270 request that was used to determine the 271 response.
The implementation guide acknowledges that the minimum compliant response described above may not completely meet the business needs of the requester. It describes the ideal response as replacing the need to have a provider's office make a phone call to the health plan.
The implementation guide recommends that an entity that will be receiving the 271 response design its system to be able to accept all of the data segments and data elements so that it will have the flexibility to receive complete standard responses from any information source.