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Charge Batches / Eligibility Tab

Charge Batches / Eligibility Tab

Sept 19, 2024

 

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:
  1. Click Charge Batches from the Manage list.
  2. Click the Eligibility tab.
  1. Open the Manage menu and select Charge Batches.
  2. Click the Eligibility tab.
  1. Press [Alt] + [M] + [C].
  2. 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

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.

Rank

System-generated

(pulled from submitted Eligibility Request)

Yes

Rank the eligibility submission is on the case.

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