Eligibility is the front-of-house fact-checker for every visit. It runs a real-time X12 270/271 against the patient's coverage at scheduling, again at T-24 hours, and once more at check-in — then translates the dense 271 response into a one-screen benefits summary the front desk and clinician can act on. When prior authorization is required, it submits an X12 278 or a FHIR Da Vinci PAS bundle to the payer and tracks the decision to closure on the 72-hour expedited / 7-day standard SLA mandated by CMS-0057-F.
Independent practices today learn that a patient's insurance is inactive, the deductible has reset, or a procedure needs prior auth on the day of service — sometimes after the patient is already in the exam room. Front desk staff re-key insurance cards into a clearinghouse portal, copy benefit details onto sticky notes, and chase down referral letters by fax. Billers rework rejected claims that could have been blocked at scheduling. Patients get surprise bills weeks later because no one had an accurate good-faith estimate at booking. Eligibility solves this by making the benefits picture canonical, structured, and present at every workflow gate from booking through claim submission.
A photo of the front and back of the insurance card is OCR'd — payer ID, member ID, and group number populate the Coverage record automatically, and a 270 fires to validate before the patient leaves the lobby. The six-tab manual clearinghouse workflow collapses into one screen.
A 270 fires automatically at slot confirmation (point-of-scheduling check), again via a T-24h batch job that re-verifies every appointment 24 hours out, and once more at check-in (or pulls a cached response under 4 hours old). Coverage flips are caught before the patient is at the desk, not after.
The parsed 271 EB segments are translated into a payer-agnostic BenefitDetail row set: copay, deductible, deductible remaining, coinsurance, OOP max, and OOP remaining — all displayed in a one-screen summary the front desk and clinician can act on immediately. Referral and prior-auth requirement flags surface inline.
Planned CPT codes are priced against the parsed benefit detail (copay vs. deductible-applied vs. coinsurance) using RCM contract rates, and shown to the patient at booking. Multi-coverage COB iterates rank order and reduces remaining responsibility by the prior payer's expected payment. Target: ±15% variance on ≥ 85% of estimates.
When a benefit signals "requires PA," a one-click ePA action builds a PriorAuth row and submits via X12 278 (legacy) or FHIR Da Vinci PAS Bundle (mandatory for CMS-0057-F-impacted payers from January 2027). Decision tracking closes on the 72-hour expedited / 7-day standard window. Status pings the ordering clinician's inbasket.
Visit types that require active coverage are blocked from confirmation when the 270 returns inactive — with an explicit self-pay override path and an audit event. Denial root causes move from post-claim rework to pre-visit prevention.
Five domain noun-apps cover the Eligibility surface on the IC platform:
InsurancePlan, Coverage, EligibilityCheck, BenefitDetail, and PriorAuth. All five
are org-scoped operational data — they carry
OrganizationID as the Cosmos partition key and the standard four-field
audit trail. Patient identity is global (Patient = User);
FKs cross the boundary cleanly per DEC-RH-002.
The 270/271 transaction flow is the backbone of every eligibility check. On dispatch, an EligibilityCheck row is created with the trigger reason (Booking, T-24h, CheckIn, Manual). The clearinghouse (Stedi primary, Availity backup with automatic failover) routes the 270 to the payer. On 271 receipt, the response is parsed into BenefitDetail rows and the Coverage active flag is updated. Every transaction carries a trace number and is retained for 7+ years per compliance requirements.
The parsing layer maps each EB segment in the 271 to a BenefitDetail row keyed by (ServiceCategoryString, CoverageLevelString, InNetworkBool). Unknown EB04 codes are recorded with the raw value preserved and flagged for parser review. The parsed output drives the front-desk benefit summary, cost-estimate math, PA-required flags, and eligibility-driven workflow gating.
| Metric | Target | Why It Matters |
|---|---|---|
| 270/271 round-trip latency p95 | ≤ 3 seconds (payer healthy) | Inline-with-booking experience requires sub-page-load response. |
| Eligibility check coverage at booking | ≥ 99% of confirmed appointments | Anything missed shows up as a denial weeks later. |
| Parsed-benefit accuracy vs. payer EOB | ≥ 98% | Cost estimates and gating only useful if parsing is right. |
| T-24h re-verification rate | ≥ 95% of next-day appointments | Catches mid-month coverage flips before front desk does. |
| ePA submission-to-decision median | ≤ 24 hours | Well inside CMS-0057-F's 72-hour / 7-day window. |
| Eligibility-related front-end denial rate | ≤ 0.5% of submitted claims | Most should be caught at scheduling; remainder is unavoidable mid-cycle changes. |