Overview

The Eligibility page is comprised of three tabs:

The Eligibility / Configuration tab is used to define and configure eligibility functions in Connect. It is comprised of two sections: 

  • General Information / Enterprise Rules
  • Practice Configuration

The Enterprise Rules section includes rules to automate Eligibility checks and place case holds for all practices at the enterprise level.

A practice can be selected and rules can be customized for it via the Practice Configuration section. Rules set at the Practice level will override those set at the Enterprise level.

How to Get Here?

From the Home Page:From the Menus:
  • Click Eligibility from the Admin list.
  • Open the Admin menu and select Eligibility.

 


Field Definitions

Field

Type

Required 

Description

General Information Section




Enterprise Rules

Free Text (Numeric)

Yes

These options are used for configuring the eligibility checks for the organization. 

Automatically check eligibility when error check is run and do not check eligibility if there has been a submission for a DOS in the last ___ days.

The value used to evaluate if an eligibility check should be included in an error check, based on when it was last previously run, for example, 45 days. Enter the number of days to use to determine submission. A value between 0 and 999 can be entered. Only mapped/supported payers are submitted for an eligibility check, based on the Subscriber ID + Patient Name + Plan.
Do not check eligibility if there has been a submission for a DOS in the last ___ days.The value used to evaluate if an eligibility check should be run, based on when it was last previously checked, for example, 45 days. Enter the number of days to use to determine submission. A value between 0 and 999 can be entered. 
Apply ___ case hold reason when Rejected eligibility response is received.

The Case Hold Reason value assigned to a case hold automatically generated if the Eligibility response is Rejected. The case is put on hold with the selected reason and assigned to the user who ran the Eligibility check.

Apply ___ case hold reason when Inactive eligibility response is received.

The Case Hold Reason value assigned to a case hold automatically generated if the Eligibility response is Inactive. The case is put on hold with the selected reason and assigned to the user who ran the Eligibility check.

Un-check insurance from case when an Inactive eligibility response is received.

If selected, the insurance is automatically removed from the case if the Eligibility response is Inactive and there are other ranked insurance present. 

Only check Rank 1 insurance on the case.

If selected, only the Rank 1 insurance is checked on the case when an Eligibility check is submitted.

Exclude Medicare crossover plan.

If selected, Medicare crossover plan is not included when an Eligibility check is executed.

Assign automatic case holds to default assignee: ___.

Designates who the case is auto-assigned to if it is automatically placed on hold.

Practice Configuration Section




Practice

Display Only

(Pulled from created/updated Practices)

YesA listing of all practices for the account with override eligibility setup information (level).
Assignment Level

Display Only

(Pulled from Update button info population)

Yes

Eligibility assignment level designation of the practice.

  • If eligibility task assignment is tied to the enterprise level rules, the "Enterprise" value is displayed in the field.
  • If eligibility task assignment is customized to follow practice specific rules (defined via the Update button), the "Practice" value is displayed in the field.

Button Descriptions

Button

Shortcut Keys

Description

Step-By-Step Guides

Practice Configuration Section

 
Update[Alt] + [U]

To update and add/remove customized configuration rules to the selected practice.

These rules will override the set Enterprise rules.


  1. Select the practice to be updated from the list of practices in the Practice Configuration table.
  2. Click Update. The General Information window opens to set the customized rules for the selected practice.

  3. Update the practice rules, as needed. 
  4. Click Save. The General Information window closes and the Assignment Level field updates to Practice for the selected practice.
Delete Override[Alt] + [D]To remove the customized practice rules and return it to the Enterprise level configuration.
  1. Select the configured practice to be changed back to Enterprise level configuration.
  2. Click Delete Override. The configuration rules are removed and the Assignment Level field updates to Enterprise for the selected practice.





 

Related Topics

Eligibility

Eligibility / Payer Mappings Tab

Eligibility / Excluded Payers Tab

Creating Payer Mappings



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