Eligibility verification

Check coverage before the session starts, not after the claim denies.

ABACare builds the X12 270 request, reads the 271 response, sorts AAA rejections into retry or correct-first, and detects coordination of benefits. Where live transmission is not switched on, a biller records what the payer portal says, with an attestation.

An eligibility check is a case too.

The response is evidence, code classifies it, and a person decides what to do with a gap. This is the product, on a fictional clinic.

From inquiry to coverage summary.

  1. 270 request

    ABACare builds the X12 270 from client demographics, payer ID, subscriber and dependent information, validated against the clinic's enrolled payer list before dispatch.

  2. 271 response

    The 271 is parsed into a structured summary: active or inactive status, benefit periods, copay, deductible, coordination of benefits and service-level benefits.

  3. AAA classification

    AAA rejections are read with their reject code and follow-up action, then routed to a retry or to a correction queue. They are not just logged.

  4. Coordination of benefits

    Primary and secondary payers are detected from the 271 response and attached to the client record, so billers know which payer pays first.

What happens when an eligibility check fails.

The payer's AAA follow-up action decides the path. C, N or S, or none at all, is sent to a billing or intake correction queue and is never resubmitted blindly. R, W, X or Y is a transient condition that is safe to retry.

  • AAA 72. Invalid or missing subscriber or insured ID.
  • AAA 75. Subscriber or insured not found.
  • AAA 58. Invalid or missing date of birth.
  • AAA 42. Unable to respond at current time.

A repeat check for the same client and payer inside a 24-hour freshness window re-uses the stored result instead of calling the payer again, and every result is labelled fresh or stale.

A worked example, a Monday-morning check.

An example with invented figures, to show how the chain works. It is not a customer result and not a prediction for your clinic.

  1. Evidence

    A new client's first session is on Thursday. The record holds the payer, the subscriber's ID and the client's date of birth.

  2. Rule

    The 271 comes back with an AAA 72 on the subscriber ID and a follow-up action that is not retryable, so the check goes to the correction queue.

  3. Proposal

    ABACare names the field to correct. It does not guess a member ID.

  4. Approval

    Front desk staff confirm the ID with the family and enter it.

  5. Action

    The check runs again. It returns active coverage, with a secondary payer detected for coordination of benefits.

  6. Audit

    Both results are stored. A second check on Wednesday, inside the 24-hour window, re-uses the stored result and says how fresh it is.

What ABACare does today, and what it does not.

  • Does: build the 270, parse the 271, classify AAA rejections, detect coordination of benefits and cache results, all exercised on synthetic data in the demo.
  • Does: record a portal-checked result. A billing user checks the payer's portal and records coverage, plan, member-ID confirmation and prior-authorization facts with an attestation, and the record names the portal as the method.
  • Does not: send live 270 requests for a clinic until live transmission is switched on for that clinic. Until then the portal lane is how a check is recorded.
  • Does not: use real payers in the demo. The demo clinic stubs 271 responses, so you can rehearse the workflow without contacting a payer.

Questions about ABA eligibility checks.

What are a 270 and a 271?
They are the X12 eligibility inquiry and response. The 270 asks a payer about a member's coverage, and the 271 is the answer, with status, benefits and any other payers.
How fresh is an eligibility result?
A repeat check for the same client and payer inside a 24-hour window re-uses the stored result, and every result is labelled fresh or stale. The window is the same for every payer.
What if the payer says the subscriber was not found?
The AAA rejection is read with its follow-up action. A rejection that must be corrected goes to a correction queue with the field named, and ABACare does not resubmit it blindly.
Do I need a clearinghouse to use eligibility checks?
Not to start. A billing user can check the payer's portal and record the result with an attestation. Live 270/271 transmission needs a clearinghouse path that is switched on for your clinic.