I would like to know what responses are the most important and commonly looked for in an Electronic Eligibility response?
- Covered Vs Not Covered
- Deductible
- Co-Insurance
- Dates of Coverage (Coverage Started ##/##/####, End Date ##/##/####)
- In Network Vs Out of Network
- Other Carrier (ex. Medicare Supplemental)
- Service Type ( Ex. Radiation Therapy, Chemotherapy, etc. There are 193 types http://www.wpc-edi.com/referen.....ype-codes/ )
- Procedure Specific coverage
- Other…ie
If you choose to respond to this post, it would be useful to rank them in the order of importance/priority.
In regards to workflows, the quick and generalized workflow is something similar to:
- Review the upcoming patient schedule for the following core items
- Carrier - to know how to get eligibility information (website, call, automation) and additional requirements such as auth/referral
- Appointment Type – Complex and pricey services require deeper eligibility research – specialty or procedure coverage, cert, auth or referral requirements
- Facility
- Provider
- Last Verification date – first appointment of month, first appointment of year, or may need to verify every visit – ex: Medicaid
- New or Existing Patient - additional documentation may be necessary for practice.
- Find and record the required information – this is the most challenging as automated responses can provide too much or too little information. Carrier websites or phone systems vary greatly.
- Reference the first list above.
- Update Centricity registration fields and active coverage status
- Attach additional information if needed in Centricity
- Record or notify external systems/sources of findings. ex. EMR, Secure email
- Work/log issues - such as deductibles, co-pays, expired coverage, partial coverage and etc
- Process to handle on-demand and add-on appointments - as the practice may have a separate scheduling team.
- Maintain history of eligibility verification - to be referenced when claim denials are associated with eligibility issues.
If you have any examples of your Eligibility Workflows and would be willing to share a HIPAA compliant example, that would be appreciated. (A free and easy screen capture tool that has a blur function to obfuscate patient information is Skitch http://evernote.com/skitch/ )
Interesting Eligibility Links
Navigant - Independent Insurance Eligibility Verification A Cost/Benefit Review for Immunization Billing
http://public.health.oregon.go.....eening.pdf
Tips for Streamlining Workflow: Eligibility
http://dailypracticeblog.com/t.....igibility/
HIMSS patient access checklist
http://www.himss.org/files/HIM.....Access.pdf
CMS information on Electronic Eligibility
http://www.cms.gov/Research-St.....de5010.pdf
Full Disclosure and permission to move/remove topic: I work for a company that is creating an Eligibility add-on for Centricity. This is not meant to solicit sales and any responses will not result in marketing emails, private messages or calls.
Posted : September 6, 2014 2:29 am
