Billing Eligibility

(Topic Last Updated On: 09/14/2015)

The Billing Eligibility menu item on the Accounting menu launches the Billing Eligibility screen, which is used by facilities using Methasoft's third party billing functionality to view the results of 270 EDI Health Plan Benefit Coverage requests set to third party Payers. These results are populated based on the 271 EDI message received from the Payer and/or Clearinghouse. The Search criteria fields allow users to filter the results by Sent Date, Payer, Status, Patient ID, and/or Requested By (the Methasoft user who initiated the Eligibility Check). The Status column is color-coded to clearly identify which patients have Active coverage, Inactive coverage, requests that have been Sent but not yet responded to, and requests which generated an Error at some point within the 270 inquiry/271 response cycle. The Details button can be pressed for a selected Eligibility Check to show a window with detailed information received on the 271 EDI response. This screen is integrated with the Messages panel on the left side of the Methasoft user interface, so that when Billing Eligibility Checks Sent or Received links are pressed, this screen opens and displays the corresponding messages on the grid. The Create/Send Batch button is used to launch a Select Patient window, where users can filter the list of available patients to include for sending batch 270 EDI transmissions.

Field Descriptions

Sent From

This field is used to filter the responses shown on the grid by selecting the date on or after an eligibility check was sent. When this screen is opened, this field is auto-populated with a date 90 days prior to the current date.

Sent To

This field is used to filter the responses shown on the grid by selecting the date on or before an eligibility check was sent.

Payer

This field is used to filter the responses shown on the grid by displaying only eligibility checks for the Primary Payer/Rate Group associated with the patient's current / effective Billing Episode at the time an eligibility check was sent. The Primary Payer/Rate Group shown may or may not match the Primary Payer/Rate Group associated with the patient's current / effective Billing Episode, because this screen always displays the Primary Payer/Rate Group at the time at which the eligibility check was sent, after which a patient's Billing Episode could end and a new one be created with a different Primary Payer/Rate Group.

Status

This field is used to filter the responses shown on the grid by displaying only eligibility checks of the selected Status.

Patient ID

This field is used to filter the responses shown on the grid by displaying only eligibility checks sent for the entered Patient ID.

Requested By

This filter is used to filter the responses shown on the grid by displaying only eligibility checks sent by the selected Methasoft User ID.

Grid Columns

Status

This column is color-coded and displays the status of each eligibility check based on the 271 EDI response message received. 'Sent' indicates that the outgoing 270 message was sent, but has not yet been responded to. 'Active' indicates that the returned 271 message indicated the patient's insurance coverage is active for the date range provided. 'Inactive' indicates that the returned 271 message indicated the patient's insurance coverage is inactive for the date range provided. 'Error' indicates that a 270 message was generated and sent, but that somewhere along the path to the clearinghouse and/or third party payer through the returned 271 message, an error occurred while processing either the 270 or 271 message.

Patient ID

This column displays the Patient ID of the patient for each eligibility check response.

Patient Name

This column displays the First and Last Name of the patient for each eligibility check response.

Payer

This column displays the Primary Payer/Rate Group to which each eligibility check was sent, based on each patient's current / effective Billing Episode at the time each eligibility check was sent.

From Date

This column displays the Effective Date of each patient's Health Plan Benefit Coverage as returned by the Payer/Rate Group on the 271 EDI response message.

To Date

This column displays the Expiration Date of each patient's Health Plan Benefit Coverage as returned by the Payer/Rate Group on the 271 EDI response message.

Sent On

This column displays the date and time on which each 270 EDI eligibility check message was sent.

Trace Ref. ID

This column displays the unique Trace Reference Number generated by Methasoft when each 270 EDI message was generated. This value is exported in a TRN segment of the outgoing 270 EDI check message, and is returned in a TRN segment of the incoming 271 EDI response message.

Command Buttons

Pressing this button will populate the grid with eligibility check records / responses based on the Search criteria field selections made.

Clear

Pressing this button will clear the Search criteria fields and return the screen to its initial state, displaying all eligibility checks / responses sent over the past 90 days.

Details

Pressing this button or double-clicking on a grid row will open the Eligibility Status Message window for the selected check / response as shown in the screen shot below. This window displays additional detailed information for each 271 EDI response received.

Create/Send Batch

Pressing this button opens the Select Patient window shown below, which allows users to filter the list of Available patients then add them to the list of Selected patients for whom a batch of eligibility checks will be sent when the Ok button is pressed.

Pressing this button closes the Billing Eligibility screen.

Procedures

How to Filter Eligibility Check / Response Searches
1.) (Optional) Make selections and/or enter data in one or more of the Search criteria fields (Sent From, Sent To, Payer, Status, Patient ID, Requested By). 2.) Press the Search button. The grid will display all records filtered by any Search criteria entered and/or selected.

How to Access the Details of an Eligibility Check / Response
1.) Double-click an eligibility check / response on the grid, or select an eligibility check / response on the grid and press the Details button. This will open the Eligibility Status Message window displaying detailed information for the selected check / response. 2.) Press the Close button to close the Eligibility Status Message and return to the Billing Eligibility screen.

How to Access Eligibility Checks / Responses from the Messages Pane
When Eligibility Checks are sent from the Patient Payments screen, the Messages tab on the left hand navigation panel of Methasoft's UI is periodically updated to reflect the number of 270 EDI eligibility check messages sent and 271 EDI response messages received, as shown in the screen shot below: 1.) To view all messages that have been 'Sent', select the 'Sent (#)' link. This will open the Billing Eligibility screen displaying only the specific 'Sent' eligibility check messages this link is informing a user of. 2.) To view all messages that have been 'Received', select the 'Received (#)' link. This will open the Billing Eligibility screen displaying only the specific 'Received' response messages this link is informing a user of.

How to Submit Batch Eligibility Checks for Multiple Patients at Once
1.) Press the Create/Send Batch button. This opens the Select Patient window as shown below, for selecting the patients to include in the batch of eligibility checks being submitted. 2.) (Optional) Make selections as in the 'Counselor', 'Pt. ID/Name', 'Phase Level', 'Payer/Rate', 'Site', and/or 'Site Group' filter field(s) as needed to filter patients out of the Available grid. 3.) Select a patient on the Available grid and press the Add > button to move the selected patient to the Selected grid, so that the patient is included in the batch 270 EDI transmission. Pressing the Add All >> button will add all patients listed on the Available grid to the Selected grid. Selecting a patient in the Selected grid then pressing the < Remove button will return a patient from the Selected grid to the Available grid. Pressing the Remove All >> button will return all patients listed on the Selected grid to the Available grid. 4.) Once the list of patients on the Selected grid includes all patients for whom an eligibility check is being submitted, press the Ok button. A Batch Check Submitted confirmation dialog message will appear as shown below. 5.) Press the Ok button on the Batch Check Submitted confirmation dialog window to close the message and return to the Billing Eligibility screen.

Considerations

Eligibility Checks Require Patients to Have a Current / Effective Billing Episode Associated with a Third Party Payer/Rate Group

Outgoing 270 EDI eligibility check messages can only be sent to a third party Payer or clearinghouse, who sends it to a third party Payer. This requires that a patient for whom an eligibility check is being performed has a current / effective Billing Episode containing the necessary data (e.g., Subscriber / Member ID) for a valid 270 EDI message to be generated. Generally such Payer/Rate Groups are set up in Methasoft with an 'Advanced' Validation Level, which requires more data entry on Billing Episodes and other screens than 'Basic' Validation Level Payer/Rate Groups, to ensure that valid 837P, 835, and/or 270/271 EDI messages are valid.

Payer/Rate Groups to Whom Eligibility Checks are Submitted Must be Associated with a Properly Configured Receiver Format Record

On the Payer/Rate Groups screen, the 'Receiver Format' field is used to associate a third party Payer/Rate Group with a Receiver Format record. This is necessary so that ISA header segment data is valid for outgoing 270 EDI messages, as well as for defining the delimiters that will be used to separate segments, data elements, and components (sub-elements).

Associated Receiver Format Records Must Be Properly Configured in Order for Outgoing 270 EDI Messages to Receive a Valid 271 EDI Response

Before your facility begins sending Eligibility Check (270 EDI) messages, it's important that all information for one or more associated Receiver Format records is properly configured. Missing or invalid ISA and/or Delimiter data will result in invalid 270 EDI messages, which will be rejected by a clearinghouse and/or third party Payer.

Additional Configuration Might be Necessary for Your Facility to Submit Outgoing 270 EDI Messages to Receive Valid 271 EDI Responses

Before your facility begins sending Eligibility Check (270 EDI) messages, various system configuration settings and/or Preferences (System-Preferences) must be set properly. Depending on your facilities needs, some configuration settings might require intervention by Methasoft Training, Support, or Technical staff. Contact Methasoft Customer Support at (877) 538 - 5767 for help.