How eligibility responses fit the workflow

An eligibility workflow moves a request from a submitter through a route to a payer and returns either a 271 response or a separate processing outcome. The transport status answers a different question from the benefit result.

Request and route

The submitter sends a 270 health care eligibility benefit inquiry. The route may include a clearinghouse, which can apply its own connectivity, validation, or translation behavior. The payer receives the inquiry only after the route’s requirements are met. CMS describes the HIPAA 270/271 transaction at the program level; a payer companion guide supplies local details.

Acknowledgments and response

The route can produce outcomes at several layers:

• A transport or connectivity error means the payload did not complete the intended exchange.
• A TA1 reports an interchange-level acknowledgment.
• A 999 reports functional-group or transaction-set syntax and implementation errors. X12’s RFI 1498 discusses named 999 error codes.
• A 271 is the application response that can carry benefit information or a request-level AAA error.

Handle each outcome at its own layer. A 999 reports validation results. A 271 reports the eligibility response, including request-level AAA errors when applicable.

Payer-specific behavior

Payers and intermediaries can require enrollment, specific identifiers, date windows, or connectivity options. For example, the CMS HETS companion guide defines HETS-specific operational requirements. Apply them to HETS traffic; other routes publish their own requirements.