Charge Batches / Eligibility Tab

Overview

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

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.

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 Eligibility tab.

(Click an image below to enlarge.)

Charge Batches / Eligibility Tab:

Eligibility Summary / Demographics Tab:

Eligibility Summary / Benefits Tab:

Eligibility Summary / Errors Tab:

Eligibility Summary / Actions Tab:

Field Definitions

Field	Type	Required	Description
Filters Section	Filters	No	Allows the list of cases to be filtered by Batch ID, Case ID, Patient, and/or Status. 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. 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. 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.
Facility	Display Only (pulled from submitted Eligibility Request)	Yes	The name of the facility 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.
DOS	Display Only (pulled from submitted Eligibility Request)	Yes	The date the service was rendered on the case.
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
Actions	Display Only (pulled from submitted Eligibility Request response)	Yes	The number of system recommended, open actions found in the response. The number is adjusted as you reject or apply the actions.
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. Any fields with no information provided by the payer will display blank. If the payer returns a different First, Middle, Last Name, Member ID, Subscriber ID, Subscriber Address: Street, City, State, Zip and Patient Address: Street, City, State, Zip, then the differing information 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 Begin 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 Type, 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	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. 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.
Actions Tab			The 271 Response may provide actionable insights included updated data and/or additional payers. The Actions Tab consolidates this information into a sign location and allows for simple rejecting or applying of these changes.
Actionable Insights Section
Select	Checkbox	No	To identify and select the action(s) to apply or reject the suggested action.
Field Name	Display Only (pulled from 271 Response)	Yes	The name of the field or data with a variation between the submitted Eligibility request and the returned 271 response.
From	Display Only (pulled from 270 Request)	Yes	The value submitted in the Eligibility request for the field identified in the Field Name field.
To	Display Only (pulled from 271 Response)	Yes	The value returned in the Eligibility response for the field identified in the Field Name field.
Status	Read-only (system-generated)	No	The status of the action. It is automatically populated by Connect based on your activity. [blank] - No action has been taken. Rejected - The action was selected (via Select checkbox) and the Reject Action button was clicked, not applying the change. Applied - The action was selected (via Select checkbox) and the Apply Action button was clicked, applying the change.
Additional Payers Section
Payer Type	Display Only (pulled from 271 Response)	Yes	The ranking of the payer. Options include: Payer Primary Payer Secondary Payer Tertiary Payer
Name	Display Only (pulled from 271 Response)	Yes	The name of the additional payer.
ID Type	Display Only (pulled from 271 Response)	Yes	The type of information presented by the ID returned for the additional payer, e.g., Member Identification Number.
ID	Display Only (pulled from 271 Response)	Yes	The unique identifier of the additional payer.
Date Type	Display Only (pulled from 271 Response)	No	The type of date information being provided and populated in the Begin Date and/or End Date fields, e.g., Coordination of Benefits, Eligibility.
Begin Date	Display Only (pulled from 271 Response)	No	The start date for the date information provided in the 271 response and applicable to the additional payer.
End Date	Display Only (pulled from 271 Response)	No	The end date for the date information provided in the 271 response and applicable to the additional payer.
Status	Read-only (system-generated)	No	The status of the action on the additional payer information. It is automatically populated by Connect based on your activity. [blank] - No action has been taken. Rejected - The additional payer was selected and the Reject Action button was clicked, not adding the additional payer information. Applied - The additional payer was selected and the Apply Action button was clicked, adding the additional payer information.

Button Descriptions

Button	Shortcut Keys	Description	Step-By-Step Guides
Search	[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).
	Not applicable	To refresh the Actions tab.	Click the Refresh icon. The actionable insights lists and Actions field counts will update based on the actions/additional players rejected or applied.
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 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.
Case Hold	[Alt] + [O]	To place a case on hold from the Eligibility tab.	Select the case to hold. Click Hold Case. The Create Case Hold Reason window opens with the selected Case(s) ID populated. Open the Case Hold Reason drop down list and select an option. The Status field defaults to Open and does not need to be changed. (Optional) Open the Assign To drop own list and select an option. Note: The Case Hold will default to be assigned to you and does not have to be changed. (Optional) Add a Note. If added, the note displays in the lower Note section. Click Save.
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. The .txt file being exported is the full 271 Response file returned from the payer.
Account	[Alt] + [A]	To open the Account / Active AR tab for the account associated with the Eligibility request.	Click Account. The Account / Active AR tab opens.
Actions Tab
Select All/None		Provides a convenient way to select/de-select all actionable insight actions. The button toggles between values upon selection.
Reject Action/Apply Action	Not applicable	To reject or apply the 271 response's actionable insights to the data.	Click the Select button for the actionable insight you'd like to either reject or apply. Click Reject Action to not apply the changes. The Status field for the selected action(s) updates to Rejected; OR Click Apply Action to apply and make the suggested changes. The Status field for the selected action(s) updates to Applied and the changes are made to the data in Connect. Once an actionable insight has been applied, it cannot be reversed via the action buttons. If the actionable insight is rejected, you can re-select it and reverse action and apply the changes.
Reject Action/Create Insurance	Not applicable	To reject or add the 271 response's additional payer information.	Select the additional payer you would like to either reject or add. Click Reject Action to reject, or not add, the payer. The Status field for the selected payer updates to Rejected; OR Click Create Insurance to open the Create Insurance and add the new insurance details. The Create Insurance window opens with the additional payer information pre-populated. Complete the steps for adding the insurance.