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Eligibility Inquiry (270) Request - PM

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Request client eligibility information to be included in a 270 file. This form flags benefit inquiry information for a subscriber, and includes this information in the next submitted 270 file. Through the Eligibility Inquiry (270) request, the following information can be gathered in myAvatar PM:

  • Generic inquiry - Does a subscriber have coverage under a guarantor or payor?
  • Specific inquiry - Does a subscriber have coverage for a specific service or procedure? This information includes: benefit amounts, co-insurance, co-pays, and deductibles. Types of specific inquiries:
    • Service code
    • Procedure code
    • Procedure code and diagnosis code

Note: This form does not provide a history of benefit use for the subscriber and does not process batch inquiries.

The Eligibility Inquiry (270) Submission form is used to submit a benefit eligibility inquiry.

Prerequisites: 

  • The Enable 270/271 Transaction Sets registry setting must be enabled.
  • A service code must be associated with Service Type Code (270) (in the Service Codes form) to be included in a 270 request file.
  • Guarantors must have the 270 transaction set enabled through the Guarantors/Payors form, to be available for selection in this form.
  • Liability should be updated for charges in the 270 file (Close Charges form).
  1. Go to: Avatar PM > Billing > Electronic Submission > Eligibility Inquiry (270) Request
  2. In the Client ID field, enter the client name or ID, and select.
  3. In the Episode Number field, select the client episode.
  4. In the Guarantor field, select the guarantor. This list contains all guarantors assigned to the selected client and episode, that have the 270 transaction set enabled in the Guarantors/Payors form (Eligibility Inquiry/Response (270/271) section).
  5. Choose Select Pending Inquiry to display the Select Pending Inquiry screen. Select an inquiry and then Ok. Inquiries for either a service code, or a CPT-4 code can be selected.
  6. In the Request Type field, select whether to run a Generic or a Specific request. Generic requests do not require service codes.
  7. In the Service Code field, enter the service code, and select. This field is used for a specific service code eligibility request. 
  • The service code must be associated with a service type code (Service Type Code (270) field, Service Codes form).
  • Service codes that have Health Benefit Plan Coverage selected in the Service Type Code (270) field are used to create a generic eligibility inquiry.
  1. In the CPT-4 Code field, enter the CPT-4 code, and select. This field is used for a specific CPT-4 code eligibility inquiry request.
  2. In the Modifier field, enter the modifiers assigned to the CPT-4 code. Separate each modifier with a comma (for example: M1,M2,M3,M4).
  3. In the Diagnosis Code field, enter the diagnosis code, and select.
  4. In the From Date field, enter the eligibility inquiry request start date.
  5. In the Through Date field, enter the eligibility inquiry request end date.
  6. Select Add/Update Inquiry to create a benefit eligibility inquiry request, or update a benefit inquiry.
  7. If appropriate, select Delete Inquiry to remove a benefit inquiry request. 
    • Deleting a benefit inquiry removes it from this form.
    • Information contained in the benefit inquiry can be compiled again in this form.
► Additional Sections
► Registry Settings

  • Enable 270/271 Transaction Sets

  • Enable Admission Data Defaulting

  • Enable Procedure Codes Date Validation

  • Exclude Dashes From Subscriber Social Security Number

  • Include Only First And Last Rendered Service In 270

  • Limit Date Range

  • Maintain Unique Functional Group Control Numbers By Root System Code