What a 271 Eligibility Response Leaves Out, and When to Check the Payer Portal

Updated November 5, 2026, based on CAQH CORE, HHS's rules in 45 CFR and CMS as of that date.

A 271 eligibility response only has to carry what the HIPAA standard and the federally adopted CAQH CORE operating rules require. That means coverage status, plus deductible, copay and coinsurance for a fixed list of service types. Behavioral health service types are among the codes where a plan may leave the patient's cost details out.

So a 271 that says "active coverage" can still leave you without the copay, the visit limit or the prior authorization answer you need before the visit. This guide covers what a payer must return, what it may skip, and when to confirm in the payer portal or by phone.

If a payer offers no electronic eligibility connection at all, that is a separate problem. Our guide to insurance eligibility verification automation covers it.

HIPAA sets the format and CAQH CORE sets the minimum content

The HIPAA-adopted transaction is the X12 005010X279A1 270/271. Much of the benefit detail inside it is situational: the standard allows it but doesn't require it. CAQH CORE wrote operating rules to fill that gap. The CAQH CORE Phase II eligibility data content rule (CORE 260) puts it plainly: "HIPAA's current mandated data scope does not require all financial information needed by providers."

Federal law made part of that floor mandatory. Under 45 CFR 162.1203, HHS adopted the Phase I and Phase II CORE eligibility rules, in their March 2011 versions, effective January 1, 2013. Those include the two data content rules (CORE 154 and CORE 260), the patient last name normalization rule and the AAA error code rule.

What a payer must return

Under the adopted rules, a health plan returns coverage status and patient cost details for the service types it covers:

• The plan's base and remaining deductible, sent under service type code 30 (Health Benefit Plan Coverage).
• Copay, coinsurance and base and remaining deductible for each CORE-required service type. CORE 260 requires remaining deductible amounts "for both the Phase I required 12 Service Type Codes and an additional set of 39 other Service Type Codes." The list includes office visits (98), urgent care (UC), physical medicine (AE) and outpatient hospital (50).
• Two EB segments when amounts differ for in-network and out-of-network care.

Remaining amounts have a time limit. CORE 260 says the remaining deductible returned "is for the current time period only, i.e., as of the date of the v5010 271." If you ask about a date of service in a different benefit period, don't expect a remaining deductible.

Behavioral health service types can come back without cost details

CORE lets a plan treat some service types as discretionary for patient financial responsibility. The discretionary list in CORE 260 is 1 (Medical Care), 35 (Dental Care), 88 (Pharmacy), AL (Vision) and five behavioral health codes: MH (Mental Health), A6 (Psychotherapy), A7 (Psychiatric Inpatient), A8 (Psychiatric Outpatient) and AI (Substance Abuse).

CORE gives three reasons. A code may be too general to mean much, it may be a carve-out benefit the plan doesn't hold, or, in CORE's words, "A code is related to behavioral health or substance abuse (e.g., AI - Substance Abuse) where privacy issues may impact a health plan or information source's ability to return information."

The current CAQH CORE eligibility data content rule, version EB.2.1, keeps that discretion and extends it to telemedicine and authorization or certification information. When a plan uses it, "the coverage status of the specific benefit (service type) must be returned." For a behavioral health practice, this explains a result you may see: the 271 shows mental health coverage as active and lists no copay. That response can be fully compliant and still leave the copay unanswered.

Auth flags, visit limits and tiers depend on the payer's CORE version

Newer CORE versions ask plans for more. Version EB.2.0 (April 2022) added telemedicine benefits, maximum and remaining coverage benefits, procedure code requests, authorization or certification indicators and tiered benefits. EB.2.1 (February 2025) expanded the required service types.

Under EB.2.1, a plan "must return maximum benefit limitations and return remaining benefits" for the CORE-required remaining coverage service types. It must also say whether authorization is required, "using EB11 with codes N or Y." When it can't tell from the inquiry, it "must use EB11 with code U if authorization or certification requirements are not accessible."

The federal adoption covers the 2011 versions, not EB.2.0 or EB.2.1. The EB.2.1 rule says conformance "can be voluntarily demonstrated and certified" through CORE testing. Whether your 271 includes remaining visits or an auth indicator depends on the payer and the CORE version it follows.

Some 271s point you to another plan

Some responses tell you where the answer lives instead of giving it. Medicare's eligibility system is a clear example. The CMS HETS 270/271 companion guide says: "Questions regarding eligibility, coverage, and payment for Medicare Advantage (MA) should be directed to the appropriate MA plan(s) identified in the eligibility response." The same guide sends Part D and Medicare Secondary Payer questions to the appropriate plans.

Your screen may show less than the 271

CORE also sets rules for whoever receives the 271. Your practice management system or clearinghouse "must display or otherwise make the data appropriately available to the end user without altering the semantic meaning" of the response. If staff find more by hand than your system shows, compare the raw 271 to the screen before concluding the payer left it out.

When to check the payer portal or call

Use the 271 first, then confirm in the portal or by phone when one of these is true:

1. The service type is discretionary, such as MH or A6, and the response shows coverage status with no copay, coinsurance or deductible.
2. EB11 is U, or missing, for a service you know may need authorization.
3. You need a visit limit or remaining visits, and the response has no limitation (EB01 = F) segments.
4. The response names another plan, such as a Medicare Advantage plan or a secondary payer.
5. The date of service falls in a different benefit period, so remaining amounts won't be returned.
6. Your system's result doesn't match what staff found by hand.

What the portal shows also varies by payer. When neither the 271 nor the portal has the answer, call provider services and note the call reference number.

Frequently asked questions

Why does my 271 say active but show no mental health copay?

Mental health (MH) and psychotherapy (A6) are discretionary service types under CAQH CORE. A plan may return coverage status for them without the copay, coinsurance or deductible. Check the payer portal or call for those amounts.

What does EB11 = U mean?

EB11 is the authorization or certification indicator. Under CORE EB.2.1, a U means the plan can't determine authorization requirements from the data in your inquiry. Confirm the auth rule in the portal or with the payer before the visit.

Is a payer required to return remaining visits?

The federally adopted 2011 CORE rules don't require it. CORE EB.2.1 does require maximum and remaining benefits for certain service types, but conformance with EB.2.1 is voluntary. Whether you get remaining visits depends on the payer.

Does CORE certification mean a payer returns everything I need?

No. CORE rules are a floor. Even a certified plan may use the discretionary service types, and CORE requirements cover set service types and data, not every benefit question.

Why does the 271 differ from what the portal shows?

The 271 carries what the standard and the payer's CORE rules require, and the portal may show more. Your own system may also summarize the 271. Compare the raw response, the portal and the screen staff see.

Checking benefits a 271 didn't answer?

Champ automates portal work like eligibility checks across payer portals. We set it up and run it, so your staff sees only the finished results. If behavioral health benefits keep sending your team to payer portals, learn more here.

This post is general information, not legal, compliance or billing advice. Rules vary by payer and plan and change often, so confirm benefits with the payer's provider services before acting. Champ is not affiliated with or endorsed by CAQH, X12, HHS or CMS.