Check Eligibility Window

Overview

The Check Eligibility window is accessible from the Charge Batch / Charge Batch Information page, allowing you to select the cases for which you would like to submit an Eligibility inquiry request.

The window is comprised of three tabs:

Tab	Description	Action
Submission	The table displays all non-reversed cases by insurance (payer/plan) by billing provider(s) found in the charge batch. Note: The Check Eligibility: Submission* window only presents payers that TriZetto supports; this cuts down on the number of records being returned with a "Payer Not Supported" message.*	Eligibility requests for cases with no mapping or data issues can be selected and submitted from this tab.
Missing Mappings	This tab is only enabled and accessible if you select a non-TPS payer that is not already mapped to a TPS Payer ID. Note: If there is missing mapping present on this tab, the tab is enabled and the tab name: Check Eligibility: Missing Mappings* appears in red text.*	The workflow to create missing mappings can be initiated from this tab.
Errors	The table displays cases that are missing required data. The checkmark will identify the field(s) that need to be corrected on the case. Note: If there is a case present on this tab, the tab name: Check Eligibility: Errors* appears in red text.*	Navigate to the case and add the missing/incorrect data.

Eligibility submission requirements:

Eligibility inquiries can be submitted for a case on hold.
Eligibility inquiries can be submitted for a submitted case.
Case Status cannot be "Reversed".
Case must have a Provider defined on it.
The practice on the case must be set up as "Eligibility Enabled" with the Clearinghouse.
User must have Eligibility "Create" permissions assigned to him/her.

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.

To prevent performing multiple Eligibility checks against the same insurance, only one line per insurance on a case is displayed.

How to Get Here?

From the Home Page:	From the Menus:	*Via Shortcut Keys:*
Click Charge Batches from the Manage list. Double-click the charge batch to review. Click Check Eligibility.	Open the Manage menu and select Charge Batches. Double-click the charge batch to review. Click Check Eligibility.	Press [Alt] + [M] + [C]. Double-click the charge batch to review. Press [Alt] + [E].

(Click an image below to enlarge.)

Submission Tab

Missing Mappings Tab

Errors Tab

Field Definitions

Field	Type	Required	Description
Submission Tab
Filters Section	Filters	No	Allows the list of cases to be filtered by Case Status, Patient, Provider and/or Rank. As you type in the Patient and Provider fields, the cases in the list are filtered to show only those that match what was typed. To restore the list to all cases, clear the contents of the filters.
Cases Table
Select	Checkbox	No	Indicates whether the case is selected for submission of an Eligibility inquiry.
Case ID	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The identification number of the case.
Case Status	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The status of the case. Options include: Unsubmitted Submitted On Hold This is the Case's status, not the Eligibility Inquiry status.
DOS	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The date the service is rendered.
Payer/Plan	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The insurance payer/plan on the case with financial responsibility for the outstanding debt. Eligibility Checks for an account having more than one insurance tied to it will only perform and return details for the selected insurance(s) on the case.
Last Checked	Display Only (pulled from the system based on the last valid Eligibility Check response)	No	The status and date of service for the last Eligibility Check for the case with a valid response. If there has been no response, the field is left blank.
Rank	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The rank of the insurance on the claim: 1 represents the primary insurance 2 represents the secondary insurance 3 or greater represents a tertiary insurance
Patient	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The name of the patient.
Provider/Practice NPI	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	Displays (by default) the Practice NPI for the procedure. This information can be updated as needed. If the current NPI is null, the NPI for one of the following is pulled (in order of availability): Physician Group CRNA Group AA Group PA Group Double-click the case record (or select a case and click the Update button) to open a selection box and change the default value displayed in the field. Options include NPI values of: Provider Physician Group PA Group CRNA Group AA Group
Missing Mappings Tab
Case ID's	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	List of all case IDs in the selected charge batch that are missing payer mappings. This field could contain multiple Case IDs.
Payer/Plan	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The insurance payer/plan on the case with financial responsibility for the outstanding debt. Those listed here are missing mappings to a TriZetto Payer ID.
Clearinghouse Payer	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The Clearinghouse Payer ID - Payer Name that corresponds to the payer/plan.
TriZetto Payer ID	Display Only (pulled from system if an exact match to payer/plan on case)	No	The TriZetto Payer ID, field is defaulted blank unless an exact match is found.
TriZetto Payer Name	Display Only (pulled from system of payers/plans matching the defaulted TriZetto Payer ID, if applicable)	No	A list of all potential payer names associated to the Payer ID found in the TriZetto Payer ID column.
Errors Tab
Case ID	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The identification number of the case.
Status	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The status of the case. Options include: Unsubmitted Submitted On Hold This is the Case's status, not the Eligibility Inquiry status.
Payer/Plan	Display Only (pulled from created/updated Case* in Charge Batch)*	Yes	The insurance payer/plan on the case with financial responsibility for the outstanding debt.
Missing Data Fields	Checkboxes	No	The fields with potentially missing or incorrect data in the case. A checkmark next to any of these items signifies the information should be reviewed and updated, as necessary. DOS Prior DOS Config Non-Primary Rank Medicare Crossover Excluded Payer NPI Subscriber # Subscriber First Subscriber Last Subscriber DOB Subscriber Gender Dependent First Dependent Last Dependent DOB Dependent Relationship Dependent Gender Provider's UPIN Unsupported Payers It is possible to have checkmarks in one or more fields.
Links
TriZetto Payer Search	Link to external URL	N/A	Link to the TriZetto payer list. Use this list to identify payers that might require additional Eligibility enrollment.
EEP	Link to external URL	N/A	Link to the TriZetto Enrollment Portal site to enroll payers that require Eligibility enrollment.

Button Descriptions

Button	Shortcut Keys	Description	Step-By-Step Guides
Check Eligibility: Submission Tab
Update	[Alt] + [U]	To update the Provider/Practice NPI field's default selection.	Select the case record to be updated. You will need to select the entire record line item, not the Select checkbox in order to enable the Update button. Click Update. The Select Provider/Practice NPI window opens. Select the desired value. Click OK. The window closes and the field value on the case's eligibility request line item is updated.
Select All/Select None	[Alt] + [E]/ [Alt] + [N]	To select or de-select all records in the Check Eligibility table.	Clicking Select All checks all boxes in the Select column of the table. Clicking Select None unchecks any checked boxes in the table. The total number of records selected will appear next to the button.
Submit and Review Response	[Alt] + [V]	To submit an Eligibility Inquiry and open the Eligibility tab for the associated Charge Batch.	Select the case(s) for submission of an Eligibility request. Click Submit and Review Response. The Check Eligibility window closes and the cases are submitted. The Charge Batches / Eligibility tab automatically opens with the associated Charge Batch ID selected and the response displayed in the sub-tabs.
Submit	[Alt] + [B]	To submit an Eligibility Inquiry	Select the case(s) for submission of an Eligibility request. Click Submit. The Check Eligibility window closes. The results are returned almost immediately and can be found on the Charge Batches / Eligibility tab. For MediCal Eligibility Requests, the Provider's UPIN is required information. If the UPIN information is not documented on the Provider's record in Connect, the MediCal case row will not be selectable or eligible for an Eligibility Request submission. The UPIN information must be added to the Provider record before the Eligibility Request for the MediCal case can be submitted from this page.
Check Eligibility: Missing Mappings Tab
Map	[Alt] + [M]	To create a mapping between non-TriZetto payer and TriZetto Payer ID.	Creating Payer Mappings
Check Eligibility: Errors Tab
Override	[Alt] + [O]	To move a line item from the Errors tab to the Submission tab.	Select a line item with the Prior DOS Config, Non-primary Rank, or Medicare Crossover checked. Click the Override button. The line is moved from the Errors tab to the Submission tab so it can be submitted for an Eligibility Inquiry.