Eligibility and Benefits

Work Group 1 - Eligibility and Benefits (WG1 Eligibility Benefits)

NDEDIC's guidance around eligibility and benefits is developed and refined by Work Group 1 through a consensus building process. This NDEDIC work group is responsible for advancing the growth and adoption of electronic eligibility benefit inquiries submitted via the ANSI ASC X12 270/271 transactions.

Monthly Meeting: Fourth Tuesday of each month at 1:00 pm Pacific

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Eligibility and Benefit Transactions

Dental practices, insurance companies and clearinghouses can exchange information electronically about a patient’s dental insurance coverage through two standardized EDI transactions. The ASC X12 270: Eligibility, Coverage or Benefit Inquiry is the request transaction and the ASC X12 271: Eligibility, Coverage or Benefit Information is the response transaction.

Both transactions were developed by ASC X12 for use in healthcare overall. NDEDIC is helping the dental industry adapt and implement the transactions to meet information exchange needs specific to dental.

Adapting to Complexity of Dental Benefit Design

NDEDIC’s Eligibility/Benefit Work Group analyzes unique dental benefit plan designs and benefits/payment administration to identify ways of standardizing information for effective exchange through the ASC X12 270/271. The complexity in dental plan designs requires the exchange of much more detailed information about a patient’s coverage than what is required by the ASC X12 270/271.

New Dental Industry Guide!

Through the work group process, NDEDIC has transformed the Top 56 questions into a guidance document for the ASC X12 270/271. The Top Dental Eligibility and Benefits Questions Response Guide is a list of standard eligibility and benefit questions that large group providers agree would minimize time consuming phone calls if the questions are answered in the payer response. This Guide is currently available for free to NDEDIC Members. It also available for purchase by non-members.

Best Practice Guidance on Eligibility & Benefits Transactions for Dental Providers & Payers
Companion to ASC X12 270/271 (updated March 2020)

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