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Overview

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The Eligibility tab is used to review submitted Eligibility Requests and the associated 271 responses as provided by the payer.

Eligibility is the determination of a person's qualification or entitlement to benefits by the insurance company.Depending on the information submitted in the Eligibility Inquiry, additional information may be included in the 271 response, including:

Procedure information
Deductible information
Co-Payment details
If the patient has multiple plans
Any additional demographic data the payer has

Note
Your practice must be enrolled for Eligibility services, set up through your Clearinghouse, and given permissions in Back Office Admin in order to utilize this functionality.

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title	How to Get Here?

From the Home Page:	From the Menus:	*Via Shortcut Keys:*
Click Charge Batches from the Manage list. Click the Eligibility tab.	Open the Manage menu and select Charge Batches. Click the Eligibility tab.	Press [Alt] + [M] + [C]. Press [Alt] + 5 to navigate to the EDC Files tab.

(Click an image below to enlarge.)

Charge Batches / Eligibility Tab:

Eligibility Summary / Demographics Tab:

Eligibility Summary / Benefits Tab:

Eligibility Summary / Errors Tab:

Field Definitions

Field

Type

Required

Description

Filters Section

Filters

No

Allows the list of cases to be filtered byBatch ID, Case ID, Patient, and/orStatus.

As you type in the fields, the Eligibility requests in the list are filtered to show only those that match what was typed. To restore the list to all Eligibility requests, clear the contents of the filters.

Eligibility Requests Section

Batch ID

System-generated

(pulled from submitted Eligibility Request)

No

The unique identification number of the charge batch with the case associated to the Eligibility Inquiry.

Note
The field is a hyperlink and will take you to the Charge Batch / Charge Batch Information tab when clicked.

Case ID

System-generated

(pulled from submitted Eligibility Request)

No

The identification number of the case associated to the Eligibility Inquiry.

Note
The field is a hyperlink and will take you to the Case / Patient, Guarantor & Insurance tab when clicked.

Patient

Display Only

(pulled from submitted Eligibility Request)

Yes

The name of the patient submitted in the Eligibility Inquiry.

Payer/Plan

Display Only

(pulled from submitted Eligibility Request)

Yes

The name of the payer and plan submitted in the Eligibility Inquiry.

Practice

Display Only

(pulled from submitted Eligibility Request)

Yes

The name of the practice associated with the case submitted in the Eligibility Inquiry.

Provider

Display Only

(pulled from submitted Eligibility Request)

Yes

The name of the provider associated with the case submitted in the Eligibility Inquiry.

Status

Display Only

(pulled from submitted Eligibility Request response)

Yes

The status, or the state of being qualified or entitled to benefits. Three possible values are:

Active - patient is currently eligible
Inactive - patient is not currently eligible
Rejected - the Eligibility Inquiry did return a successful response

Request

System-generated

(pulled from submitted Eligibility Request)

Yes

The date and time the Eligibility Inquiry was submitted.

Response

System-generated

(pulled from submitted Eligibility Request)

No

The date and time the Eligibility Inquiry 271 response was returned. If the field is blank, a response has not yet been received.

Eligibility Summary Section

Eligibility Status

Display Only

(pulled from 271 Response)

Yes

The status, or the state of being qualified or entitled to benefits. Three possible values are:

Active - patient is currently eligible
Inactive - patient is not currently eligible
Rejected - the Eligibility Inquiry did return a successful response; the error will display in the Eligibility Status field, e.g., Rejected - Payer not accepting inquiries at this time

Demographics Tab

Demographic information provided by the payer in the 271 response.

Note
Any fields with no information provided by the payer will display blank. If the payer returns a different First, Middle, or Last Name, then the name change will display in red text (e.g., Patient Name submission of 'Bill' Smith was returned as 'William' Smith; 'William' displays in red text).

Patient

Display Only

(pulled from 271 Response)

No

The patient information returned by the payer in the 271 response, including: Relationship, First Name, Middle, Last Name, Member ID, Date of Birth, Gender, Street, City, State, Zip, Eligibility Begin Date, and Eligibility End Date.

Subscriber

Display Only

(pulled from 271 Response)

No

The subscriber information returned by the payer in the 271 response, including: First Name, Middle, Last Name, Member ID, Date of Birth, Gender, Street, City, State, Zip, Eligibility Start Date, and Eligibility End Date.

Plan Detail Information

Display Only

(pulled from 271 Response)

No

The plan detail information returned by the payer in the 271 response, including: Plan Name, Plan #, Plan Begin Date, Plan End Date, Group Name, Group #, Policy Name, and Policy #.

Benefits Tab

Explanation of Benefits provided by the payer in the 271 response.

Filters

No

Allows the list of cases to be filtered by Coverage Level, Type of Service or Benefit.

Benefit

Display Only

(pulled from 271 Response)

Yes

The eligibility or benefit for of the patient with the submitted plan. Example values include: Active, Inactive, Co-Insurance, Co–Payment, Deductible.

Network

Display Only

(pulled from 271 Response)

No

Classification as to whether the insurance coverage is in network or out. Values include:Yes, No, Unknown, Not Applicable.

Coverage Level

Display Only

(pulled from 271 Response)

No

Defines who is covered by the benefit, Example values include: Individual, Children Only, Employee Only, Spouse and Children, Family.

Type of Service

Display Only

(pulled from 271 Response)

No

Defines the type of service being covered by the Benefit. Example values include: Medical Care, Surgical, Anesthesia, Hospitalization.

Plan

Display Only

(pulled from 271 Response)

No

The name of the plan for which the patient has been checked for eligibility against. This field is only populated if the Benefit for this line item is Active or Inactive and the Service Type Code is Health Benefit Plan Coverage.

Time Period

Display Only

(pulled from 271 Response)

No

Defines the time period for which the patient is eligible for the benefit. Example values include: Hour, Day, Year, Visit, Exceeded, Not Exceeded, Lifetime.

Amount

Display Only

(pulled from 271 Response)

No

The monetary amount, or value of the benefit. If the Benefit for this line item one of the following, then the Amount value in this field is the responsibility of the patient: Co-Payment, Deductible, Out of Pocket, Non-Covered, Spend Down.

Note
The Amount field is left blank if the amount is not included in the 271 response.

Patient Owes (%)

Display Only

(pulled from 271 Response)

No

The percentage amount that the patient is responsible for if the Benefit is Co-Insurance.

Quantity

Display Only

(pulled from 271 Response)

No

Defines the amount, or quantity, of which the patient is eligible for the benefit. Example values include: Number of Co-Insurance Days, Deductible Blood Units, Hours, # of Services or Procedures, Quantity Approved, Visits.

Auth

Display Only

(pulled from 271 Response)

No

Identifies if authorization is required for the benefit. Values include:Yes, No, Unknown.

Payer Message

Display Only

(pulled from 271 Response)

No

Provides additional explanation of the Type of Service. It is only used if a Type of Service value is not sent in the 271 response.

Limitations

Display Only

(pulled from 271 Response)

No

The III Segment in the Eligibility response (as provided by the Payer). It is used to determine eligibility/benefit limitation in one of the following 2 ways:

benefits are limited to a specific type of facility, i.e., Place of Service
call out nature of injury codes, e.g., injured body part such as arm

Errors Tab

If the payer returns an error message for the 271 Response, the Errors Tab provides details and insight on the issue and how to resolve it.

Request Validity

Display Only

(pulled from 271 Response)

Yes

Provides clarity as to whether the Eligibility Inquiry was a valid request and successfully submitted.

Reject Reason

Display Only

(pulled from 271 Response)

Yes

The reason for which the Eligibility Inquiry was rejected and a valid 271 response was not returned.

Follow-Up Action

Display Only

(pulled from 271 Response)

Yes

Detail about next steps to take in resolving the issue and successfully submitting the Eligibility Inquiry.

Button Descriptions

Button

Shortcut Keys

Description

Step-By-Step Guides

SearchSearch

[Alt] + [S]

To search for an Eligibility requests.

Click Search. The Search Criteria window opens.
Enter the search criteria.
Click OK (or press Alt+O)..

Resubmit Inquiry

[Alt] + [R]

To resubmit the Eligibility Request.

Select the Eligibility Request record from the list.
Click Resubmit Inquiry. The same 270 will be generated and resubmitted.

View View Inquiry

[Alt] + [V]

To open and view the 270 request tied to the Eligibility Request.

Select the Eligibility Request record from the list.
Click View Inquiry. The View Inquiry window opens in Notepad with the 270 request details.

Export 271

[Alt] + [E]

To initiate a download of the 271 response.

Click Export 271. The Save As window opens.
Select the save location.
(Optional) Update the File Name. Note: The File Name defaults to the date and time the report is generated.
Click Save.