Say This
Coverage appears active for the checked service date.
Reference 0006
Eligibility Triage Card
A compact model for using 270/271 eligibility checks before claim submission without treating them as payment guarantees.
Use this when registration, scheduling, estimates, or claim-prep workflows say eligibility is active, inactive, unmatched, or unclear.
The Boundary
Eligibility answers coverage questions. It helps prepare accurate claims, determine patient liability, and check service eligibility. It does not adjudicate a future claim.
Four Buckets
| Code | Bucket | Question | Common Product Action |
|---|---|---|---|
| IDN | Identity | Can the payer match the patient, subscriber, member ID, DOB, and relationship? | Correct demographics, subscriber, member ID, or relationship data. |
| ACT | Active coverage | Was coverage active for the service date? | Block claim prep, collect updated coverage, or choose another payer. |
| BEN | Benefits | What coverage details apply to this service type or plan context? | Show service-specific warnings and route authorization tasks if needed. |
| OOP | Out of pocket | What deductible, copay, coinsurance, or patient responsibility signals appear? | Create an estimate while preserving uncertainty until adjudication. |
Safe Product Language
Avoid This
Payer has guaranteed payment for this claim.
Store This
Payer, service date, patient/subscriber facts, response timestamp, raw response, parsed bucket signals, and uncertainty notes.
Source Anchors
- CMS Health Plan Eligibility Benefit Inquiry and Response explains that the 270/271 transaction obtains eligibility and coverage information for an enrollee.
- CMS Eligibility Inquiry says HETS 270/271 data is intended for preparing accurate claims, determining beneficiary liability, or checking eligibility for specific services.
- CMS Operating Rules for Eligibility and Claims Status describes real-time eligibility responses with financial information such as deductibles, copays, coinsurance, and coverage for specific service types.
- CAQH CORE Operating Rules identifies eligibility and benefits operating rules for consistent infrastructure and data content requirements.