Submitting and Viewing Eligibility Using Revenue Cycle

Eligibility can be submitted in Revenue Cycle using both person and encounter-level conversations with checks occurring automatically through batch Cerner Millennium Operations jobs or manual submission. In any instance, the responses can be seen using the Insurances or Insurances with Profiles tables.

Each table has dedicated columns, which can display the status of an eligibility submission. The following columns can be used to reference eligibility status:

• Elig Submitted: The date that an eligibility request left the system.
• Transaction Status: The current status of the eligibility transaction (initiated, pending, error, completed)
• Alerts: If an alert comes back for an eligibility message, position the pointer over the alert for more information.
• Cache Date: The date the initial eligibility request left the system. Only supported with Medical Eligibility
• Cache Expire Date: The date the eligibility transaction expires. Only supported with Medical Eligibility
• Submitted By: User who submitted eligibility
• Coverage Status: Coverage based on the 271 eligibility response (for example, Active, Inactive, Non-Covered, and Payer Rejection)

For additional details about managing insurances in Revenue Cycle, see Working With Registration Conversations: Insurance Management.

Submitting an Eligibility Transaction

Regardless of whether the transaction was submitted manually or automatically, the transaction flow for sending and receiving is the same. In both scenarios, the patient and encounter information is retrieved and the ANSI 270 eligibility request transaction is created and sent to Transaction Services. From there, the transaction goes to the clearinghouse and then to the payer. The payer processes the transaction and creates an ANSI 271 eligibility response, which is sent back through the clearinghouse to transaction services. This entire process takes anywhere from a few seconds to several minutes, depending on the availability of the payer’s eligibility systems.

If the patient or subscriber's Name on File with Payer values are populated in the conversation, the system sends an outbound 270 transaction with those values to the payer. If these values are left blank, the current name of the subscriber on the health plan, as well as the patient's name, is sent to the payer in the eligibility request.

Eligibility transactions can be submitted to the payer through four methods:

• Automated Submission: Submit eligibility through an Operations Job. Encounters are automatically updated and errors can be reviewed through a dedicated work queue
• Manual Submission (Registration Conversation): Submit an eligibility check for an individual patient or encounter in a registration conversation. Users can immediately update registration information based on payer response
• Manual Submission (Appointment Perspective): Verify insurance eligibility at the patient level before scheduling an appointment
• Submit from Eligibility Queue: Resubmit eligibility from within the work queue to attempt to resolve errors
• Alternate Payers: submit an eligibility request to two payers simultaneously

Automated Submission

Automated submission is accomplished through a Cerner Millennium Operations job, an automated process that selects multiple future appointments and submits each eligibility request as an individual real time transaction for each patient.

The function of the eligibility Operations job is to submit eligibility for created encounters, whether for all active insurances associated with an appointment, or for the primary insurance associated with an appointment.

This job typically runs between 2 a.m. and 4 a.m. An encounter must be created before an eligibility request can be sent to the payer. Creating an encounter and submitting eligibility 48 hours in advance allows you to work the eligibility queue and verify that patients coming in for services have active benefits. For example, Facility ABC automatically submits eligibility through an Operations job for all active insurances associated with an appointment two days before the appointment.

Transactions sent by this Operations job are displayed as sent by a generated domain user.

Additional Insurance Table Eligibility Options

Right-click on the Insurance table to access the following options:

• Add Insurance: Add another insurance to the encounter.
• View Insurance: View the insurance details (only available when not in Modify mode).
• Modify Insurance: Modify insurance on the encounter
• Remove Insurance: Remove the insurance from the encounter.
• Sequence Insurances: Sequence the insurances on the current encounter.
• Submit Eligibility: Submit an eligibility transaction for the selected insurance.
• Submit Eligibility for All Insurances: Submit an eligibility transaction for all active and effective insurances associated with the current encounter.

• 1-000000305899
• 1-000000305127
• 1-000000296772

• Eligibility Details: View the returned eligibility response.
• Previous Transaction: View the previously returned eligibility response.

Previous Transaction

When you select Eligibility Details, a Previous Transaction option is also displayed.

This option is also available using the context menu command when you select a health plan.

See Overview of Common Financial Clearance View Previous Transactions for more information about using previous transactions with Common Financial Clearance Medical Eligibility .

With Medical Eligibility, you can view all past transactions for a specific payer and alternate payer. You can still select Eligibility Details to view the most recent Medical Eligibility response, as well as any alternate payer info and the Transaction History table.

Manual Submission Through an Encounter

Manual submission is processed through both Add and Modify Encounter and Person conversations. Submission of eligibility also includes opportunities to submit eligibility through the patient check-in process and through patient tracking. Eligibility and benefit information is stored with the encounter, so the encounter must exist before you can check a patient’s eligibility.

Complete the following steps to manually submit an eligibility transaction to the payer:

1. Select Modify.
2. Select the appropriate insurance in the patient’s encounter.
3. Select Submit Eligibility.

The transaction is submitted to the payer immediately, and when the response is received, the screen automatically is refreshed and details for the eligibility and benefits are displayed. When transactions are manually submitted, a response is polled for two minutes. During that time the submission is put in a Pending status and the Submit Eligibility option is disabled. Keep the patient record open and the eligibility and benefit information for the patient is automatically displayed.

Additional Insurance Table Eligibility Options

Right-click on the Insurance table to access the following options:

• Add Insurance: Add another insurance to the encounter.
• View Insurance: View the insurance details (only available when not in Modify mode).
• Modify Insurance: Modify insurance on the encounter
• Remove Insurance: Remove the insurance from the encounter.
• Sequence Insurances: Sequence the insurances on the current encounter.
• Submit Eligibility: Submit an eligibility transaction for the selected insurance.
• Submit Eligibility for All Insurances: Submit an eligibility transaction for all active and effective insurances associated with the current encounter.

• 1-000000305899
• 1-000000305127
• 1-000000296772

• Eligibility Details: View the returned eligibility response.
• Previous Transaction: View the previously returned eligibility response.

Submit Eligibility with Options

The Submit Eligibility with Options workflow allows you to submit eligibility with a service type up front from a context menu command.

You can select the following options to submit with service types up front:

• Submit Eligibility with Options: Submits the selected options for the selected health plan.
• Submit Eligibility for All with Options: Submits the selected options for all health plans on the Insurance table.
  

Once the dialog box opens, you can select from the following options:

• Coverage Date Range: Range to check to determine if the patient had coverage. Default value is today's date.
• Service Types: Types can be moved from the Available list to the Selected list. Default Selected list values are configured in Revenue Cycle Maintenance. See Configuring Eligibility Settings using Revenue Cycle Maintenance for more information on service types.
• Override Cached Response: By selecting this option, you can override any cached response that may have run for the health plan.

The Override Cached Response option is available only to clients who use Medical Eligibility in Revenue Cycle.

All above options can be used independently of each other. If you only need to submit for a coverage date, you can select the coverage dates with which you want to submit, no other options, and select OK .

Previous Transaction

When you select Eligibility Details, a Previous Transaction option is also displayed.

This option is also available using the context menu command when you select a health plan.

See Overview of Common Financial Clearance View Previous Transactions for more information about using previous transactions with Common Financial Clearance Medical Eligibility .

With Medical Eligibility, you can view all past transactions for a specific payer and alternate payer. You can still select Eligibility Details to view the most recent Medical Eligibility response, as well as any alternate payer info and the Transaction History table.

Manual Submission Through the Appointments Perspective

Eligibility submissions through the Appointments perspective are at the patient level.

Complete the following steps to submit eligibility in the Appointments perspective:

1. In Revenue Cycle , search for and select a patient.
2. Click Appointments on the toolbar.
3. In the Demographic view, click Submit Eligibility next to the insurance heading. Eligibility is submitted for each applicable insurance plan.
   

Additional Insurance Table Eligibility Options

Right-click on the Insurance table to access the following options:

• Add Insurance: Add another insurance to the encounter.
• View Insurance: View the insurance details (only available when not in Modify mode).
• Modify Insurance: Modify insurance on the encounter
• Remove Insurance: Remove the insurance from the encounter.
• Sequence Insurances: Sequence the insurances on the current encounter.
• Submit Eligibility: Submit an eligibility transaction for the selected insurance.
• Submit Eligibility for All Insurances: Submit an eligibility transaction for all active and effective insurances associated with the current encounter.

• 1-000000305899
• 1-000000305127
• 1-000000296772

• Eligibility Details: View the returned eligibility response.
• Previous Transaction: View the previously returned eligibility response.

Submit Eligibility with Options

The Submit Eligibility with Options workflow allows you to submit eligibility with a service type up front from a context menu command.

You can select the following options to submit with service types up front:

• Submit Eligibility with Options: Submits the selected options for the selected health plan.
• Submit Eligibility for All with Options: Submits the selected options for all health plans on the Insurance table.
  

Once the dialog box opens, you can select from the following options:

• Coverage Date Range: Range to check to determine if the patient had coverage. Default value is today's date.
• Service Types: Types can be moved from the Available list to the Selected list. Default Selected list values are configured in Revenue Cycle Maintenance. See Configuring Eligibility Settings using Revenue Cycle Maintenance for more information on service types.
• Override Cached Response: By selecting this option, you can override any cached response that may have run for the health plan.

The Override Cached Response option is available only to clients who use Medical Eligibility in Revenue Cycle.

All above options can be used independently of each other. If you only need to submit for a coverage date, you can select the coverage dates with which you want to submit, no other options, and select OK .

Previous Transaction

When you select Eligibility Details, a Previous Transaction option is also displayed.

This option is also available using the context menu command when you select a health plan.

See Overview of Common Financial Clearance View Previous Transactions for more information about using previous transactions with Common Financial Clearance Medical Eligibility .

With Medical Eligibility, you can view all past transactions for a specific payer and alternate payer. You can still select Eligibility Details to view the most recent Medical Eligibility response, as well as any alternate payer info and the Transaction History table.

Submit from Eligibility Queue

If using the eligibility queue to follow up on incomplete eligibility transactions, encounters can be manually resubmitted from within the queue. Right-click a specific encounter and select one of the following options related to eligibility:

• Eligibility Details: Opens a dialog box that displays the eligibility details for the patient or encounter selected from the queue.
• Resubmit Eligibility: Resubmits the eligibility request for the patient or encounter in context.

Additional Insurance Table Eligibility Options

Right-click on the Insurance table to access the following options:

• Add Insurance: Add another insurance to the encounter.
• View Insurance: View the insurance details (only available when not in Modify mode).
• Modify Insurance: Modify insurance on the encounter
• Remove Insurance: Remove the insurance from the encounter.
• Sequence Insurances: Sequence the insurances on the current encounter.
• Submit Eligibility: Submit an eligibility transaction for the selected insurance.
• Submit Eligibility for All Insurances: Submit an eligibility transaction for all active and effective insurances associated with the current encounter.

• 1-000000305899
• 1-000000305127
• 1-000000296772

• Eligibility Details: View the returned eligibility response.
• Previous Transaction: View the previously returned eligibility response.

Submit Eligibility with Options

The Submit Eligibility with Options workflow allows you to submit eligibility with a service type up front from a context menu command.

You can select the following options to submit with service types up front:

• Submit Eligibility with Options: Submits the selected options for the selected health plan.
• Submit Eligibility for All with Options: Submits the selected options for all health plans on the Insurance table.
  

Once the dialog box opens, you can select from the following options:

• Coverage Date Range: Range to check to determine if the patient had coverage. Default value is today's date.
• Service Types: Types can be moved from the Available list to the Selected list. Default Selected list values are configured in Revenue Cycle Maintenance. See Configuring Eligibility Settings using Revenue Cycle Maintenance for more information on service types.
• Override Cached Response: By selecting this option, you can override any cached response that may have run for the health plan.

The Override Cached Response option is available only to clients who use Medical Eligibility in Revenue Cycle.

All above options can be used independently of each other. If you only need to submit for a coverage date, you can select the coverage dates with which you want to submit, no other options, and select OK .

Previous Transaction

When you select Eligibility Details, a Previous Transaction option is also displayed.

This option is also available using the context menu command when you select a health plan.

See Overview of Common Financial Clearance View Previous Transactions for more information about using previous transactions with Common Financial Clearance Medical Eligibility .

With Medical Eligibility, you can view all past transactions for a specific payer and alternate payer. You can still select Eligibility Details to view the most recent Medical Eligibility response, as well as any alternate payer info and the Transaction History table.

Submitting an Eligibility Request for an Alternate Payer

Alternate payer functionality is not supported with Common Financial Clearance Eligibility.

To support alternate payers, you can submit an eligibility request to two payers simultaneously. This functionality can be used in the situation where a patient may be eligible for Medicare or Medicaid but also has a Managed Medicare or Managed Medicaid policy through a commercial payer. Complete the following steps to submit an eligibility request to an alternate payer in addition to the primary payer :

1. In the Insurance tab of a Revenue Cycle conversation, select Add Insurance to add the patient’s primary insurance information.
2. Enter the primary payer's name in the Search for Health Plan box or select Search.
3. Select the plan you want to add, and select Select Eligible Plan.
4. Enter all required information, and select OK.
5. In the row for the primary payer, select Submit Eligibility. The system checks eligibility for both the primary and alternate payer.
6. If information exists for an alternate payer, an icon is displayed in the Alternate Payer Indicator column, and specific information is displayed for that payer in the following row.

The following columns can also be added to Insurance Tables to view Alternate Eligibility information:

• Alternate Eligible
• Alternate Alerts
• Alternate Eligibility Cache Date
• Alternate Eligibility Cache Expire Date
• Alternate Eligibility Submit Date
• Alternate Submitted By

Additional Insurance Table Eligibility Options

Right-click on the Insurance table to access the following options:

• Add Insurance: Add another insurance to the encounter.
• View Insurance: View the insurance details (only available when not in Modify mode).
• Modify Insurance: Modify insurance on the encounter
• Remove Insurance: Remove the insurance from the encounter.
• Sequence Insurances: Sequence the insurances on the current encounter.
• Submit Eligibility: Submit an eligibility transaction for the selected insurance.
• Submit Eligibility for All Insurances: Submit an eligibility transaction for all active and effective insurances associated with the current encounter.

• 1-000000305899
• 1-000000305127
• 1-000000296772

• Eligibility Details: View the returned eligibility response.
• Previous Transaction: View the previously returned eligibility response.

Submit Eligibility with Options

The Submit Eligibility with Options workflow allows you to submit eligibility with a service type up front from a context menu command.

You can select the following options to submit with service types up front:

• Submit Eligibility with Options: Submits the selected options for the selected health plan.
• Submit Eligibility for All with Options: Submits the selected options for all health plans on the Insurance table.
  

Once the dialog box opens, you can select from the following options:

• Coverage Date Range: Range to check to determine if the patient had coverage. Default value is today's date.
• Service Types: Types can be moved from the Available list to the Selected list. Default Selected list values are configured in Revenue Cycle Maintenance. See Configuring Eligibility Settings using Revenue Cycle Maintenance for more information on service types.
• Override Cached Response: By selecting this option, you can override any cached response that may have run for the health plan.

The Override Cached Response option is available only to clients who use Medical Eligibility in Revenue Cycle.

All above options can be used independently of each other. If you only need to submit for a coverage date, you can select the coverage dates with which you want to submit, no other options, and select OK .

Previous Transaction

When you select Eligibility Details, a Previous Transaction option is also displayed.

This option is also available using the context menu command when you select a health plan.

See Overview of Common Financial Clearance View Previous Transactions for more information about using previous transactions with Common Financial Clearance Medical Eligibility .

With Medical Eligibility, you can view all past transactions for a specific payer and alternate payer. You can still select Eligibility Details to view the most recent Medical Eligibility response, as well as any alternate payer info and the Transaction History table.

View Eligibility Details

Once eligibility has been submitted, the response can be reviewed by selecting the Eligibility Details button on the appropriate table.

Two eligibility detail windows may be available:

• Common Financial Clearance Eligibility
• Medical Eligibility

Common Financial Clearance Eligibility

View Coverage Status

Complete the following steps to view coverage status information:

In the Eligibility Details dialog box, view the Health Plan/Payer Name element below the patient name. The following icons are displayed:

The Historical Response alert is only displayed if you enable the Historical Processing option in the associated domain. If this option is disabled, the Historical Response alert is not displayed.

The Verify Status field for the health plan is automatically updated to Verified if the eligibility status comes back as Active or Yes Follow Up if the eligibility status comes back as Inactive, No Coverage, or Payer Rejection. The following additional values are available for the Verify Status field and can be manually selected by a user after eligibility is checked on the health plan.

• Denied: Manually updated value if patient's insurance is denied
• Not Applicable: Manually updated value used if insurance verification does not apply to the specific health plan
• Pending: Manually set value if patient's insurance information is pending
• Required: Default value for the Verify Status field
• Verified: Indicates successful eligibility transaction and that patient has eligibility coverage
• Error: Manually updated status for insurance if patient's insurance information is in error
• Yes Follow Up: If eligibility submissions come back as inactive coverage

View Patient or Subscriber Information

Complete the following steps to view patient or subscriber information:

1. Open the Eligibility Details dialog box.
2. From the Patient / Subscriber panel, view the demographic information. Verify that the displayed information is correct.
   
3. If the information is incorrect, update the health plan information as necessary.
4. View the Primary Care Provider box and determine if the payer sent the patient's primary care provider (PCP).
5. If the PCP is displayed, verify that the information matches the patient registration.
6. View the Third Party Liability panel and determine if the payer sent the necessary information.
   
7. From the Managed Care panel, determine if the payer sent the necessary information.
   

Select and View Benefit Information

Complete the following steps to select and view benefit information:

1. In Revenue Cycle (RevenueCycle.exe), open the Eligibility Details dialog box and view the Benefits panel.
2. From the Service list, select the appropriate service.
3. From the Network list, select the appropriate network option.
4. From the Benefits panel, view the following information:
   
   • Co-payment
   • Co-Insurance
   • Deductible
   • Out of Pocket
   • Limitations
   • Reserve
   
5. If necessary, select All Benefits to view additional information.
   
6. If any alerts are displayed, select the associated links to view extra information.
7. If applicable, select and copy the co-payment amount and paste the value into the Financial Responsibility box in the registration conversation.
8. After verifying the benefit information, select the Apply Benefits to Encounter button to copy the benefits to the benefit organizer in the Insurance tab.
9. Verify that the following message is displayed: Benefits applied to Encounter.
10. As necessary, repeat Steps 1 through 9 to view additional benefit information. After all benefit information is added, you can view this information in the benefits organizer in the Insurance tab.
    

Complete the following steps to manually add a benefit:

1. Modify the encounter conversation.
2. On the Insurance Benefit table, select the Add button.
3. In the Add Benefit dialog box, enter any required values.
   
4. When you are finished, select OK. The newly added benefit now is displayed on the Insurance Benefit table.
   

View and Update Discrepancies

In the Common Financial Clearance interface, if any differences exist between the information submitted in the request and the information the payer has on file, a discrepancy alert is displayed. Information contained in Cerner Millennium i s displayed in the Current row, while the response from the payer is displayed in the Response row.

• To update Cerner Millennium with the data received from the payer, select Accept.
• To reject the discrepancy, select Reject and the information is not updated in Cerner Millennium .
• To change the previous action of Accept or Reject, select Edit and then select Reset to override the previous selection.

Complete the following steps to view and update discrepancies:

1. Open the Eligibility Details dialog box.
2. View the Discrepancies panel and determine if one or more of the following discrepancies exist:
   • Health Plan
   • Patient Name
   • Birth Date
   • Gender
   • Member ID
   • Group Number
   • Group Name
3. If a discrepancy exists, review the information and select Accept or Reject. When all discrepancies are resolved, the following message is displayed: All discrepancies resolved.
   
   • If you select the Accept button, the information is displayed in the health plan information in the Revenue Cycle conversation.
   • If you select the Reject button, the information from the payer is not displayed in Revenue Cycle, but is still displayed on the eligibility response.

If patient demographic discrepancies are accepted back from the eligibility response, those values are copied into the Patient on File with Payer fields and used on subsequent eligibility inquiries. If Cerner Patient Accounting (CPA) is used for Patient Accounting, the Patient on File with Payer fields are not used on the claim. If your site uses RevElateis used for Patient Accounting , the Patient on File with Payer fields are used on the claim to minimize claim rejections. See Understand Insurance Information Between Cerner Millennium and Soarian Financials for additional information.

Add Additional Payers and Plans

The Additional Payer/Plan window is currently available only to sites using the Blaze Rules Development Tool (BRDT) in RevElate.

Facilities using the Blaze Rules Development Tool (BRDT) in RevElate can add new health plans to patients based on the initial eligibility response.

• Select Add Health Plan to add the plan to the patient's encounter.
• Select Reject to decline the addition.

Once the health plan has been added to the encounter, sites should run eligibility to verify the patient's plan coverage. This can be done automatically or as part of a workflow established to manually verify. See Overview of Automatically Adding a Health Plan or Accepting a Health Plan Discrepancy in Revenue Cycle for additional details.

Review Messages and Alerts

Complete the following steps to review messages and alerts:

1. Open the Eligibility Details dialog box.
2. Review the Messages panel for messages and alerts and take the appropriate action. When all messages or alerts have been resolved, no further action is necessary.
   

Review Support Information

Complete the following steps to review the support information:

1. In the Eligibility Details dialog box, view the Support Information panel.
2. Select Inquiry Details and view the data sent to the payer on the eligibility inquiry.
   
3. Select Transaction Reference Details and view the data related to the transaction for troubleshooting.
   
4. Select Close.
5. Once all information has been reviewed, select OK to close the Eligibility Details dialog box.

Verification Fields

You can use verifications fields as a way to inform the user if eligibility was viewed and ran successfully.

Cerner Millennium Operations Job Workflow

In this workflow, the request is submitted using an Operations job, and the eligibility response is returned. The verification status and corresponding fields are initially blank, and the verification status is not automatically set when the response is returned. The response is added to an unverified work queue until a user views it in Edit mode.

Manual Workflow

In this workflow, the user manually submits the eligibility request, and a response is returned. The verification fields are initially blank. When the user selects Eligibility Details, the verification status is automatically set to Verified or Follow Up in the following scenarios:

• Verified: The status is set to Verified if the following conditions are met :
  • Common Financial Clearance UI is opened in Edit mode.
  • The coverage status is set to active.
  • Common Financial Clearance UI is opened in Edit mode
  • The coverage status is set to a value other than active, such as actives, multiple coverages, inactive, no coverage, or payer rejection.

  When the verification status is valued, the following fields are also valued:

  • Verify Date: The date when the verification status was initially set
  • Verify source: Automated
  • Verify personnel: The user ID of the user who viewed the eligibility response

  Updates to Verification Status Fields

  When the verification status fields are valued and eligibility is run again, t he verification status, verify date, verify source, and verify personnel values are updated only if the value for verification status was originally Follow Up and the new value is Verified.

  Otherwise, the verification status fields are not automatically updated.

  The verification status is not automatically set if the response returned is an error or if the eligibility response is viewed in View Only mode.

  Medical Eligibility

  

  In the Medical Eligibility interface, you can see the service types that were sent on the eligibility request in the Service Type column on the Transaction History table.

  The service types can also be seen to the right of the Filters check box in the eligibility response.

  See the Filters subsection of the Details section below for more information.

  Transaction History View

  The top portion of this view includes a list of all the submission dates for this encounter. The bottom section provides the detailed information of what was returned for each of the submissions. Select a row in the top portion. The details related to that submission are displayed in the Details view in the lower portion of the screen.

  The following columns are displayed in the top section:

  

  • Submitted Date
  • Received Date
  • Check Status: indicates the status of the transaction, for example, Verified, Error, or Denial.
    • If the transaction has an Inactive status, the Details view table is not populated.
    • If the transaction has an Error status, the Details view is not displayed, but a transaction error message is displayed.
  • Alerts: If the Alert icon is present, this indicates that an alert message (for example, authorization is required) is associated with the health plan. The icon is displayed only if an alert message is associated with the health plan’s latest eligibility transaction.
  • Cache Date: Indicates when the eligibility for the selected transaction was cached.
  • Cache Expire Date: Indicates when the eligibility for the selected transaction expires.
  • Transaction ID/Trace ID: The Transaction Services Transaction ID used for troubleshooting (TRANSACTION_ELIGIBILITY.transaction_source_ident).
  • Service Type: The service types requested for the selected transaction
    

  Detail View

  Filters

  

  Filters can be used to limit the results displayed to only those relevant to the current visit. The following filters are available:

  • Service Type: Automatically populates with the service types sent for the transaction.
  • Coverage Level
  • Insurance Type
  • Status
  • Benefit Type
  • Authorization Required
  • In Network

  Selecting any filter values causes the filters indicator to be selected. The specific filters selected are displayed to the right of the Filters check box. You can deselect the filters indicator for all values to be displayed.

  

  Columns

  Information in the eligibility transaction returned from the payer is displayed in the Details view columns and includes:

  • Service Type
  • Coverage Level
  • Insurance Type
  • Status
  • Authorization Required
  • In Network
  • Plan Name
  • Type
  • Amount
  • Percentage
  • Quantity
  • Time Period
  • Place of Service
  • Comment

  

  If an icon is displayed in the Comment column, select the icon to view the actual comment in the comment area below the Detail View table.

  Enhanced Eligibility User Interface

  The Eligibility Details window provides the following information in the response:

  • Primary Care Provider Information
  • Submitted Payer Name
  • Health Plan Information
    • Member Number
    • Group Number
    • Group Name
    • Plan Number
    • Plan Name
    • Family Unit Number
    • Policy Number
    • Case Number
    • Contract Number
    • Medical Record Number
    • Patient Account Number
    • Health Insurance Claim Number
    • Serial Number
    • Card Number
    • Issue Number
    • Network Number
    • Network Name
    • Medicaid Recipient Number
    • Prior Identification Number
    • Agency Number

    
    
    
    
    

    Text View

    The third view is Text view. The actual message returned from the eligibility transaction submission is displayed in this view. Press CTRL+F to search for text in this view.

    HDX Rules-Based Messages

    HDX eligibility services use the industry-standard Accredited Standards Committee X12 (ASC X12) 270/271 transaction to communicate with payers. Although a standard format, important response information may be either hard to find or cryptic in nature. Payer-specific rule-based messages elevate important data and simplify complex response information. HDX writes and maintains rules using proprietary algorithms that evaluate payer-specific response data and produce the rule results that qualify. HDX can sequence these rules to display as the first benefits if the source does not have a specific means of displaying the rule results.

    Rules-based messages benefits:

    

    • Response data elevation: Data that is difficult to find in a response can be easily elevated so that users do not have to search for it.
    • Response data simplification: Complex responses, such as Medicare, can be simplified so that users can understand the data more easily.
    • Available rules: Rules have been written for a number of payers including Medicare, various Medicaid organizations, and commercial payers. Addition of rules for more payers is ongoing and is based on client feedback.
      

    Accept Demographic Updates

    This functionality is generally available with the Cerner Millennium 2015.01.25 Service Release .

    Task 130240 (RUN RevenueCycle Registration - Ability to accept demographic differences from the Eligibility Details dialog) is required to accept demographic updates.

    Demographic and health plan information such as name, address, member number, and group number are displayed with the insurance verification response. Cerner eligibility checking compares that information with what is stored in Cerner Millennium for the patient .

    With HDX Transaction Services, if any differences exist between the information submitted in the request and the information the payer has on file, an Insurance Demographics Differences alert is displayed. Select View to open the Demographic Differences dialog box. Information contained in Cerner Millennium is displayed in the Millennium column, while the response from the payer is displayed in the Insurance Response column. To update Cerner Millennium with the data received from the payer, select the corresponding Approve check box.

    

    The following data is updated in the corresponding On File with Payer prompts in Cerner Millennium :

    • Patient
      • First
      • Middle
      • Last
      • Suffix
      • Sex
      • DOB
      • Group Number
      • Patient Number
      • Group Name
      • First
      • Middle
      • Last
      • Suffix
      • Sex
      • DOB
      • Subscriber Number

      The following data is updated in the corresponding person-level prompts:

      • SSN
      • Home Address
        • Address Line 1
        • Address Line 2
        • City
        • State
        • Postal Code

        The following data is updated on the corresponding person-level or encounter-level prompts based on whether the submission was done at the person or encounter level:

        The Update option is not available when a dependent's information is sent to the payer in the 270 transaction, but not returned in the 271 transaction.

        The demographic differences are only compared with the patient's Cerner Millennium information. If the patient is a dependent, the demographic differences are for the dependent and not the subscriber.

        For home address differences, you can add the address as a new address or modify the existing address stored in Cerner Millennium . The Add option sets the end-effective date on the current address and adds a new address to the database. The Modify option updates the existing address in the database and does not add a new address entry.

        Select Confirm to write the selected demographic differences to the database and update the Eligibility Details view with the new information. Select Cancel to discard the changes and not make any updates.

        Verification Fields

        You can use verifications fields as a way to inform the user if eligibility was viewed and ran successfully.

        

        Verification fields can be configured in the following ways:

        Operations Job Eligibility Submission

        With this method, the request is submitted using an Operations job, and the verification fields are blank (verification status, verify date, verify source, verify personnel). When the eligibility response is returned, the verification status is automatically set to Verified or Follow Up in the following scenarios:

        • Verified: The status is set to Verified if the following conditions are met:
          • The transaction status of the eligibility response is set to active.
          • No alerts from Code Set 27143 are returned in the eligibility response. See Configure Eligibility for more information about code set configuration.
          • The transaction status of the eligibility response is set to a value other than active, such as actives, multiple coverages, inactive, no coverage, or payer rejection.
          • At least one alert defined on Code Set 27143 is returned in the eligibility response. See Configure Eligibility for more information about code set configuration.

          When the verification status is valued, the following fields are also valued:

          • Verify Date: The date when the verification status was initially set
          • Verify Source: Automated
          • Verify Personnel: The user ID

          When eligibility has been run and verification fields are valued, and the eligibility request is submitted for a second time using an Operations job, eligibility response is returned. The verification status, verify date, verify source, and verify personnel are updated if the value for verification status is different from the first response. I f the verification status is determined to be the same, none of the verification fields are automatically updated.

          Manual Eligibility Submission

          With this method, the user submits the request manually, and the verification fields are blank (verification status, verify date, verify source, and verify personnel. The verification status is automatically set to Verified or Follow Up in the following scenarios:

          • Verified: The status is set to Verified if the following conditions are met:
            • The transaction status of the eligibility response is set to active.
            • No alerts from Code Set 27143 are returned in the eligibility response. See Configure Eligibility for more information about code set configuration.
            • The transaction status of the eligibility response is set to a value other than active, such as actives, multiple coverages, inactive, no coverage, or payer rejection.
            • At least one alert defined on Code Set 27143 is returned in the eligibility response. See Configure Eligibility for more information about code set configuration.

            When the verification status is valued, the following fields are also valued:

            • Verify Date: The date when the verification status was initially set
            • Verify Source: Automated
            • Verify Personnel: The user ID

            When the verification status fields are valued and eligibility is run again, t he verification status, verify date, verify source, and verify personnel values are updated only if the value for verification status was originally Follow Up and the new value is Verified.

            Otherwise, the verification status fields are not automatically updated.

            Verify status is not populated for a transaction that results in an error. No value set in the Verify Status field is equal to not verified.

            Select and View Benefit Information

            Once Eligibility is returned, all benefits will automatically post to the Insurance Benefit table in Revenue Cycle.

            Complete the following steps to manually add a benefit:

            1. Modify the encounter conversation.
            2. On the Insurance Benefit table, select the Add button.
            3. In the Add Benefit dialog box, enter any required values.
               
            4. When you are finished, select OK. The newly added benefit now is displayed on the Insurance Benefit table.
               

            Eligibility Caching

            When you submit an eligibility request for all health plans, the system checks for a cached response. If a cached response exists for any of the health plans, the following message is displayed: One or more health plans has a cached eligibility response. Are you sure you want to submit a new transaction for those health plans that have a cached eligibility response? Select Yes to submit a new eligibility request for all health plans and override any existing cached responses. Select No to submit a new eligibility request for all health plans that do not have a cached response and to return the cached response for all health plans that have a cached response.

            Caching is configurable through a service request to the Cerner Transaction Services team. The option to use a cached response only exists when the previous eligibility request returned an Active response.

            

            Eligibility Queue

            The eligibility queue tracks all the transactions. Multiple filters are available for the queue and the default display shows the transactions with a status of In Error. From the queue, you can resubmit the transaction and access the visit so you can see all the information and track the status as you are working with the transaction.

            

            • using_practice_management_eligibility_work_flow
            • practice_management
            • revenue_cycle
            • submitting_an_eligibility_transaction_using_revenue_cycle