Claims · 2026-03-05 · 4 min
How Insurance Eligibility Verification Works
What a 270/271 eligibility check can confirm, what it cannot, and how practices should talk about copays and deductibles.
The transaction
A 270 eligibility inquiry asks a payer about a member. A 271 response returns what that payer is willing to say: often whether coverage is active, and sometimes copay, coinsurance, and deductible details. The practice management system or the clearinghouse usually sends the inquiry. A person gets involved when the response is thin or rejected.
A rejected inquiry is a data problem. It is not proof that the patient is uninsured. Nicknames, swapped subscriber and patient, and a new plan year are ordinary causes.
What you can say to a patient
If the response shows an active plan and a copay, staff can collect that copay and still call it an estimate of the visit, because the service itself may land differently. Deductible remaining is a point-in-time figure. It can change if another claim pays first.
If the response does not speak to the specific CPT code, nobody should say the service is approved. Approval is an authorization problem. Eligibility is only coverage status and basic cost sharing.
A worked example
A fictional family medicine desk sees a card that expired last month. The 271 returns inactive coverage. The patient has a new plan in a phone photo. The second check is active, with a different copay. The claim that would have been built from the old card never enters the batch. That is the entire value of the control.
The example is instructional. It is not a measured result from a practice.
Where eligibility stops
Eligibility will not code the visit, will not satisfy medical necessity, and will not replace a prior authorization for a procedure. It also will not tell you the contracted rate. Practices that want a price estimate need the benefit response and a separate fee or allowed-amount source, and they should label the result as an estimate.
Do not send member IDs or card images through a public website form. Those belong in the practice's system during an actual engagement.
A desk routine that matches the transaction
Run the inquiry when the visit is scheduled and again if the date of service moves into a new month. Store the response date next to the appointment so billing can see that the check was current. When the 271 is rejected, correct the subscriber data and send it again. Do not convert a rejected inquiry into a self-pay charge without speaking to the patient.
Train the front desk on the sentence they are allowed to say: coverage appears active, this copay is what the response showed, and the amount can change after the claim adjudicates. That sentence is more useful than a promise the transaction cannot make. Authorization status, if required, is a separate field and a separate follow-up.