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Real Time Eligibility Verification |
| Real Time Eligibility Verification process is useful to verify the patient's insurance coverage eligibility before accepting an appointment request. The request for eligibility is sent through the 270 message from a provider to a payer. The response would be sent in an 271 message which covers the patients insurance validity, benefits etc. |
| 1.Introduction |
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Outline |
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This article focuses in the Real Time Eligibility Verification process mechanisms needed to be supported by an Electronic Health Records (EHR) system. |
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Background |
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Providers of medical services must currently submit health care eligibility and benefit inquiries in a variety of methods, either on paper, via phone, or electronically. The information requirements vary depending upon: |
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Type of insurance plan |
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Type of service performed |
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Where the service is performed |
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Where the inquiry is initiated |
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Where the inquiry is sent |
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The Health Care Coverage, Eligibility, and Benefit are designed so that the inquiry submitters (information receivers) can determine |
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Whether an information source organization (e.g. payer, employer, HMO) has a particular subscriber or dependent on file |
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The health care eligibility and / or benefit information about that subscriber and/or dependent(s). |
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Thought it is possible to verify an individual’s eligibility and benefits through data available in these transaction sets, it cannot provide a history of benefit use. The information source organization may provide information about other organizations that may have third party liability for coordination of benefits. |
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With Electronic Data Interchange (EDI), the health care industry can achieve potential administrative cost savings. |
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Requirements |
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The Real Time Eligibility check process is accomplished by two Health Care Coverage, Eligibility and Benefit transaction sets. |
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The two batch-oriented ASC X12 transaction sets are: |
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Health Care Coverage, Eligibility and Benefit Inquiry (270) from a submitter (information receiver) to an information source organization. |
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Health Care Coverage, Eligibility and Benefit Information (271) from an information source organization to a submitter (information receiver) |
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The eligibility transaction sets are designed to be flexible enough to encompass all the information requirements of the various entities. These entities may include: |
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Insurance Companies |
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Health Maintenance Organizations |
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Preferred Provider Organizations |
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Health Care Purchasers |
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Professional Review Organizations |
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Social Worker Organizations |
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Health Care Providers (e.g. physicians, hospitals, laboratories) |
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Third-party Administrators |
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Health Care Vendors (e.g. practice management vendors, billing services) |
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Service Bureaus (VANs or VABs) |
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Government agencies such as Medicare, Medicaid, and Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) |
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Some submitters do not have ready access to enough information to generate an inquiry to a payer. An outside lab or pharmacy providing services to an institution may need to send an inquiry to the institutional provider to obtain enough information to identify to which payer a health care eligibility or benefit inquiry should be routed. Because of this type of situation, a 270 may be originated by a provider and sent to another provider, if inquiry is supported by the receiving provider. |
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| 2. Real Time Eligibility Verification as implemented in Care EMR |
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Areas to be addressed |
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Care EMR addresses the real time eligibility verification at two levels: |
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Patient Demographics |
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Scheduler |
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Real Time Eligibility Verification in Patient Demographics |
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Real time eligibility verification can be done by navigating to the Insurance details of the Patient Demographics page. |
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Care EMR provides two functionalities within the patient's insurance details related to real time eligibility verification. |
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Eligibility History |
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All past successful eligibility verification requests and responses are displayed in this option. |
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Verify Eligibility |
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Step 1: |
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The 'Verify Eligibility' button navigates the user to the page of the same name where the real time eligibility verification is carried out for the selected insurance of the patient. |
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On click of this option, Care EMR generates the 270 comprising the patient's insurance benefit details and sends it to the payer via GatewayEDI tool. |
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Step 2: |
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The details are checked at the payers end and the response is sent in 271 formats. |
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The details are also displayed in the screen and typically consist of the following information: |
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Member Details |
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Dependent Details |
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Eligibility and Benefit Details |
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Subscriber Benefit Details |
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Subscriber Eligibility Details |
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| In the case of the real time eligibility verification check being successful, the application appends it's details in the 'Eligibility History' grid. |
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Real Time Eligibility Verification in Scheduler |
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Real time eligibility verification can be done at the time of booking the appointment for a patient in the 'Visit Calendar' page. |
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Eligibility History |
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| All past successful eligibility verification requests and responses are displayed in this option. |
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Verify Eligibility |
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Step 1: |
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The 'Verify Eligibility' button navigates the user to the page of the same name where the real time eligibility verification is carried out for the selected insurance of the patient. |
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On click of this option, Care EMR generates the 270 comprising the patient's insurance benefit details and sends it to the payer via GatewayEDI tool. |
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Step 2: |
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The details are checked at the payers end and the response is sent in 271 formats. |
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The details are also displayed in the screen and typically consist of the following information: |
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Member Details |
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Dependent Details |
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Eligibility and Benefit Details |
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Subscriber Benefit Details |
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Subscriber Eligibility Details |
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| In the case of the real time eligibility verification check being successful, the application appends it's details in the 'Eligibility History' grid. |
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| Real time eligibility verification can be done at the time of booking the appointment for a patient in the 'Visit Calendar' page. |
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3. Conclusion |
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Care EMR has a very efficient Real Time Eligibility Verification functionality and it works in tandem with many established third-party online eligibility verification systems. |
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Easy to use, Care EMR Real Time Eligibility Verification functionality enables the provider to send and receive real time eligibility verification information in quick and correct manner. As an added incentive this also saves the provider of paper, dedicated resources and is cost effective. |
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Reference List |
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ASC X12N. INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE
Care EMR Application Guide |
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About Author:
Dev. D, Solutions Architect |
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