Real-time eligibility is an electronic check of a patient's insurance coverage and benefits while staff are working with the record. For medical benefits, a provider sends an eligibility inquiry called a 270 and receives a 271 response. The response can include active coverage, service-specific benefits, effective dates, deductibles, copays and coinsurance.
Read those details together. An “active” result for the health plan answers a different question from an immunization benefit or a confirmation that your pharmacy participates in the patient's network. For a clinical appointment, match the returned service benefit to the planned care and confirm which network terms apply at your location.
How real-time eligibility works
Staff enter or confirm the patient and subscriber information, payer, service date and provider information in their billing software or an eligibility tool. The system sends the inquiry directly or through a clearinghouse, and displays the returned benefits. A payer portal offers another way to check coverage; the available detail can differ by channel.
The 270 is the question and the 271 is the answer. Neither is a submitted medical claim. UnitedHealthcare's EDI transaction guide distinguishes eligibility from claim submission and claim-status requests. Our clearinghouse guide explains how those exchanges reach the payer.
“Real time” describes the request-and-response exchange. A batch service checks a group of patients, such as an upcoming appointment list; an individual real-time check is useful when a patient presents a new card or a coverage question needs an answer now. Available modes depend on the connection. For example, Medicare HETS accepts real-time transactions and doesn't accept batch transactions directly.
A fast response still reflects the payer's available records. Use the intended service date, and check the returned coverage dates rather than assuming today's active status answers a question about a past or future visit. Follow the payer's verification timing and supported date range; rerun the check when the patient reports a coverage change.
What the response can tell you
CMS's eligibility operating-rule overview describes financial information and coverage for specific service types. Your software may group this information into separate panels or benefit rows. Open the detail behind the summary status.
Coverage and dates. Confirm the response belongs to the intended patient or dependent, the right plan and the requested service date. Read effective and termination dates, plus any other-plan information returned. An active plan and a terminated plan are different findings from a request that couldn't match the member.
Service benefits. Find the entry for the relevant service category, such as immunizations or durable medical equipment. Health-plan coverage is a broader category. A service-type category also isn't the same as an individual CPT or HCPCS procedure code. The payer's supported inquiries determine how specific an answer you can obtain.
Cost sharing and limits. Read the copay, coinsurance, deductible and remaining-benefit information with its service category, coverage level and time period. An individual deductible and a family deductible describe different amounts; a remaining amount is different from the annual total. Don't apply a generic office-visit copay to a vaccine service without checking the applicable benefit.
Network benefit levels. A response may show both in-network and out-of-network benefits. Those amounts describe plan benefits; they don't necessarily identify which level applies to your pharmacy. UnitedHealthcare's 2026 administrative guide specifically says its electronic 270/271 member eligibility transactions don't return the provider's network status. It directs providers to confirm participation for the member's medical or pharmacy plan through its portal or chat.
When a specific question gets a general answer
An accepted inquiry doesn't always produce the detail requested. Blue Cross and Blue Shield of Texas's February 2026 companion guide says unsupported service types receive a response equivalent to general health-plan coverage.
If the returned benefit is general, use the payer's service-specific portal or provider-support route for the unresolved question. State the actual service, date, plan and provider identity. “Is this patient active?” repeats a question already answered; “Does this vaccine benefit apply at our pharmacy location under this provider's participation?” asks for the missing fact.
A prior-authorization requirement is another distinct fact. A response may identify a requirement or direct you elsewhere, but the eligibility inquiry itself doesn't submit an authorization request. Use the plan's authorization process when required. For the difference between authorization and a plan referral, see the referral-authorization guide.
A vaccine appointment with an active medical plan
Consider a hypothetical pharmacy preparing to administer a vaccine. Staff have identified the patient's medical plan as the intended billing route. The eligibility screen shows active coverage for the appointment date and an in-network preventive benefit amount. The pharmacy hasn't yet confirmed participation in that member's particular medical network.
The unresolved question is whether that benefit applies to this pharmacy and service. Staff inspect the returned immunization information, then check the payer's participation record for the location and provider identity the plan requires. If the payer confirms participation and the applicable vaccine benefit, they can use that information for the patient estimate and complete any remaining service requirements. If the payer says the pharmacy isn't participating, the displayed in-network amount can't be used as this location's estimate; staff must resolve the applicable out-of-network terms or another permitted arrangement before quoting it.
The pharmacy's ability to bill a patient's prescriptions doesn't settle this medical-network question. CMS identifies separate medical and pharmacy eligibility transaction standards. Confirm the benefit route for the particular vaccine and plan. The medical-versus-pharmacy-benefit guide explains that distinction.
No response, member mismatch and inactive coverage
A timeout or unavailable connection means the check didn't produce a usable answer. Check the service notice or retry through an available payer channel. Don't relabel a technical failure as inactive coverage.
A member or request error calls for checking the identified input. Compare the submitted member ID, name, date of birth and subscriber/dependent selection with the current insurance information. The CMS HETS companion guide distinguishes matching errors from returned eligibility information. If the source record and submitted details disagree, resolve that discrepancy instead of repeatedly sending the same request.
An inactive response requires reviewing the coverage dates and plan for the service in question. Ask about replacement coverage if the patient reports a plan change. If the patient or payer records conflict with the response, have the billing lead obtain payer clarification before using it to make a coverage decision.
For an unresolved inquiry, retain the response or payer reference in the existing patient billing record so the person following up can locate it. Record the specific question still open and who will resolve it.
Using the result for a patient estimate
Eligibility information supports a cost estimate. The final amount depends on the applicable service benefit, provider arrangement and processed claim. Blue Cross and Blue Shield of Illinois explicitly notes that final benefits can depend on intervening claims and the terms applicable on the service date. A deductible balance can therefore change between the check and claim processing.
Explain the known benefit and the unresolved condition together: “The plan reports an immunization benefit, but we're confirming whether this location participates before estimating your share.” Once the relevant facts are confirmed, identify the amount as an estimate based on the current benefit information. Resolve unexpected amounts or conflicting payer answers before presenting them as a final patient balance.
What to ask an eligibility software vendor
Ask the vendor to demonstrate your actual payer mix and clinical-service categories using test data. The demonstration should show the requested service date and provider, the complete returned benefit detail, and how staff distinguish inactive coverage from a failed request or missing information. Check whether the system preserves the response and directs unresolved cases to someone who can follow up.
Confirm payer availability, any required enrollment, supported service categories, batch versus individual checks, and fees for transactions or repeated checks. An attractive “active” indicator is useful only if staff can find the information needed for the appointment. Ask the demonstrator to open a response with both network benefit levels and explain how your team would establish which one applies.
