Healthcare Eligibility & Enrollment

HIPAAfree

Validate member enrollment data — member IDs, subscriber relationships, coverage dates, enrollment gaps, and plan types per X12 834/270/271 standards.

5 rules 557 downloads4.2 avg (34)

eligibilityenrollmentmember834270271coverageplansubscriber

4.2(34 ratings)

Test this pack with your data

Download the template, fill in your data, and see quality results instantly.

Test This Pack

Download & Install

Choose your tool — get a ready-to-run file

Run this on your data? Upload your CSV — we'll auto-map the columns, validate, and report the bad rows.Test my data

Or use the CLI

$ npx dqhub install healthcare-eligibility --format soda --table YOUR_TABLE

About this pack

Data quality checks for healthcare eligibility and enrollment data. Covers: - Member/subscriber ID format validation (4-30 alphanumeric) - Subscriber relationship codes per X12 standard (Self, Spouse, Child, etc.) - Coverage date validity (effective date before termination date) - Enrollment gap detection (no gaps > 1 day between consecutive periods) - Plan type validation (HMO, PPO, EPO, POS, HDHP, Medicare Advantage, Medicaid, Indemnity) Standards: X12 834 (Enrollment), X12 270/271 (Eligibility Inquiry/Response), HIPAA, CAQH CORE

Sources & References

HIPAA — 45 CFR 162.1203

Member identifiers in eligibility transactions must conform to X12 270/271 standards

X12 — X12 270/271 Transaction Set - Loop 2100C REF*1L

Subscriber identifier must be present and properly formatted for eligibility inquiry and response

X12 — X12 270/271 Transaction Set - INS01 Individual Relationship Code

The subscriber relationship code identifies the insured's relationship to the subscriber and must be a valid code from the X12 code list

X12 — X12 270/271 Transaction Set - DTP Segment (Date/Time Period)

Coverage date ranges must be logically consistent with effective date preceding or equal to termination date

CAQH CORE — CAQH CORE 270/271 Infrastructure Rule

Eligibility responses must contain accurate and consistent coverage date information

CMS — CMS Enrollment and Eligibility Requirements

Continuous enrollment tracking is required for Medicare and Medicaid beneficiaries to ensure uninterrupted coverage

X12 — X12 270/271 Transaction Set - EB03 (Service Type Code) / STC Segment

Benefit information responses must reflect the correct plan type for accurate eligibility determination

CMS — CMS Plan Type Classifications

Medicare and Medicaid plan types must conform to CMS-defined categories

What's included

3format rules

2consistency rules

Checks included (5)

Member/Subscriber ID Format(member_id)

Validates that member or subscriber ID values are non-null, non-empty, and contain 4 to 30 alphanumeric characters. Member IDs are critical identifiers in eligibility transactions (X12 270/271) and must be present and properly formatted to ensure accurate member matching and claims adjudication.

Subscriber Relationship Code(relationship_code)

Validates that the subscriber relationship code is one of the allowed values defined in the X12 270/271 eligibility transaction standard. Valid codes include 18 (Self), 01 (Spouse), 19 (Child), 20 (Employee), 21 (Unknown), 39 (Organ Donor), 40 (Cadaver Donor), 53 (Life Partner), and G8 (Other Relationship).

Plan Type Validation(plan_type)

Validates that the health plan type is one of the recognized plan categories: HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), EPO (Exclusive Provider Organization), POS (Point of Service), HDHP (High Deductible Health Plan), Medicare Advantage, Medicaid, or Indemnity. Correct plan type classification is essential for benefit determination and network adequacy.

Coverage Date Validity

Validates that the coverage effective date is before or equal to the coverage termination date. A termination date earlier than the effective date indicates a data integrity issue that can lead to incorrect eligibility determination and claims processing errors.

Enrollment Gap Detection

Detects gaps greater than 1 day between consecutive enrollment periods for the same member. For each member, enrollment periods are ordered by effective date, and the termination date of period N is compared to the effective date of period N+1. A gap greater than 1 day may indicate a lapse in coverage that affects eligibility determination and claims processing.