Practice InsightInstructional Webinar

SeriesEligibility ManagerPresented by:

Shaun McAnulty – Product Training Specialist

Key Items

• Eligibility Cycle• Eligibility Formats• Submission Methods• What is Eligibility Manager • Editing Eligibility Requests• Enhanced Eligibility- Beta• Questions

Eligibility Cycle

During testing requests can be marked Invalid.

Eligibility Request sent to PI prior to visit

Patient Calls to make Appointment

PI loads request, tests for valid information

Payer Sends Response

(271)

Rejected Or

Not CoveredCovered

Research Collect copay or deductible at time of visit

Charged at time of visit

Information Updated

Bill insurance as usual

PI forwards request to Payer(270)

Eligibility Formats

• ANSI 270 File from Practice Management Software• Proprietary Eligibility Flat File• Add-One button in Eligibility Manager

Response Formats• ANSI 271 • HTML (New format available)

Submission Methods

Automated(270 or Flat File)

• HTTPS: An individual request is submitted with a payer response returned.

• SFTP: Batch mode sends multiple requests and the 271 responses are posted in a response directory for pick up by your Practice Management System.

Manual

• Using the Upload Files button.

• ADD-One: Manually enter eligibility information and submit a request.

• On-Demand from a Claim.

Eligibility in Claim Manager

Any claim with a RED E will allow you to run a Real-Time Eligibility check if the option is turned on. Simply hit E for Eligibility or use your Right Click feature and the Response is returned.

What is Eligibility Manager?

• Is the main location where users can search, work, edit, view and add eligibility requests.

• All responses and request history are also located here to view at any time.

• The layout is similar to Claim Manager.

• Some questions you may have about the application may be answered in the online help guide!

• Each subsection is broken down and shows field descriptions and definitions.

• Allows keyword searching

F1 Online Help

• Eligibility Request can be added manually by clicking ADD-One button

• All Required fields are designated by an * (in yellow)• Practice Insight creates 270 to send to payer• Then a Response is displayed

ADD-One

Using these fields can aid in returning results!

Eligibility Response

• Display the 271 in user friendly format

• Stylistic and consistent layout based on what the payer sends back.

• With conflicting data displayed in Red*

Eligibility Invalids & Rejects

Invalid

• Invalid requests are never sent to the payer

• Caused by missing required data o Common invalid reasons

• This payer isn’t setup for eligibility

• Subscriber name and ID number not entered

• No provider selected• Provider not enrolled for CMS

eligibility request

Rejected

• Sent to payer and rejected for reason given o Common rejection reasons

• Unable to respond at the current time please resubmit the transaction

• Subscriber/ insured not found • Patient not covered• Incorrect member ID

Overview

MANAGE Enrollment: Will allow user to setup a providers username/login for payer websites for Enhanced Eligibility.

UPLOAD file: Button brings up a dialog box where the user can select a 270 / 271 file, or a CSV flat file to upload into the EDI software.

SELECT Records: Displays eligibility requests based upon the criteria entered in the fields of the Eligibility Selection Criteria View.

CLEAR Selections: Allows the user to clear all information from the Eligibility Selection Criteria fields.

DOWNLOAD 271: Allows the user to create a batch 271 response file to return to the Practice Management System. • All selected records in the Eligibility

List View can be batched into a 271 and downloaded to the local PC. This file can be loaded into the Practice Management System if the software has the ability to import and read the ANSI 271 transactions.

PRINT Detail: Displays the complete, printable report of the Eligibility and Benefit Information for each selected eligibility request.

PRINT List: Allows the user to print a list of all selected eligibility requests in the Eligibility List View. • Information on the Eligibility

Request List includes the EDI ID, Eligibility Request Status, Patient Name, Payer ID, Co-pay Amounts, Primary Care Provider, Coverage Status, and Date of Service.

ADD One: Allows the user to manually add an eligibility request. • Fields with an asterisk ( Payer ID,

Provider ID, Service Type, Last Name, First Name, and Member ID ) are required fields.

EDIT: Allows the user to edit an existing eligibility request.

REALTIME Check: The user can manually check the real-time status of the selected eligibility request. • Once the check is complete and the

271 is received back from the insurance payer, the Eligibility and Benefit Information screen will appear.

VIEW Change Log: Displays a report that shows all of the changes that have been made to a specific eligibility request. • This report also shows the full history of the

eligibility request at the bottom.

Right Click Options

Options in Selection View

Options for Status Message View

• Task Manager* can be paired with Eligibility to work all your invalid & rejected requests easily.

• Using the Print List button when selecting an upload file for a specific day allows you to print a quick check in sheet for front office use.

• The list of active Eligibility payers can be found by pressing [F4] on the Payer ID field or by printing a list via Search Tools

Helpful Tips & Uses

*If you don’t currently have Task Manager (Customers= contact your Vendor) (Vendors= contact your support representative at Practice Insight)

Task Manager

With Task Manager users can easily build Eligibility tasks to monitor, work, and organize their 270/271’s.

• Most common Task for Eligibility would be Invalid & Rejected Eligibility Requests.

• You can also build Tasks to pull a specific upload date.

Enhanced Eligibility

We can use a Providers Login on the Payers

website to return Eligibility responses.

Manage Enrollment is where you are able to enter and manage individual login and passwords for Payers websites which we use to access the eligibility information. We are currently in Beta-testing if interested please let your vendor know.

Question and Answer

• Customers: If you do not have Eligibility Manager or have any further questions on Eligibility Manager please contact your Vendor

• Vendors: Contact your Practice Insight support representative with any questions on todays webinar.

Who To Contact

• Your chance to give feedback• Request new topics• Ask other questions

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