edispense Vaccine Manager Coverage Inquiry

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Jack Lee
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edispense Coverage Inquiry 1 Getting Started To perform a Coverage Inquiry, open your browser, go to www.edispense5.

If there are multiple sites, select the site where the patient is being seen and the vaccine administered.

1 edispense Coverage Inquiry 1 Getting Started To perform a Coverage Inquiry, open your browser, go to Click on Menu,, Coverage Inquiry 2 Enter Patient Information/Check Eligibility Select Site: If there is only one site assigned to the User, the system will default to the assigned site. If there are multiple sites, select the site where the patient is being seen and the vaccine administered. New Patient: Verifying a patient s eligibility is the most effective way to insure you have the most up to date information for a patient. To verify eligibility, complete the required information (patient name, gender, date of birth, and social security number). All other information is optional, but could be beneficial for claims payment follow-up. Existing Patient: You can select a patient already in the system by clicking on the search button next to the patient s last name. Enter all or a portion of any one of the search criteria and click search. Select, highlight and doubleclick on patient or select highlight and click on Select. If 30 days has passed since the patient visit, an updated eligibility will be preformed. Once the required patient information fields are completed, click Check Eligibility. Verified/Confirmed eligibility information will provide the information needed to process the claim. This information will include the patients Plan, Card Holder ID, Group Number, and may include special notes or claims information. Click Update Patient. The insurance information will populate in Section 2. Select the patient relationship in section 2 and Proceed to Step 3 Enter Medication Information. If the Eligibility Response is Rejected or an error message is received, reconfirm the patient infor-

2 3 Please mation is correct and repeat the Eligibility Inquiry or click Update Patient and proceed to Step 2, Enter Insurance Information. Enter Insurance Information request to see the patient s Medicare Prescription Card. It is recommended that a copy of the patient s card be maintained in the patient chart/financial record. Successful eligibility checks will populate the insurance plan, and card ID. If Rejected you will have elected to manually Enter Insurance Information In either case, the relationship of the card holder to the Patient must be selected. The relationship/card holder, and the patient will usually be the same for Medicare patients. Once completed proceed to Step 3 Enter Medication Information. 4 Select If the Patient does not have his/her Medicare Prescription Card and the patient eligibility comes back rejected, the patient will need to submit a paper claim (See 6 - Paper Claim Process). Enter Medication Information the prescribing physician and the vaccine/medication. The quantity will always default to 1 and the date will default to today s date. When the appropriate vaccine or medication is selected, the Bill Amount defaults to a predetermined Usual and Customary Charge (U&C). This can be changed by simply typing over the Bill Amount. When the Coverage Inquiry button is selected the system will ask if you want to save the new Bill Amount as your new default Usual and Customary. If you select OK, the new charge will be saved as the Usual and Customary. If you select Cancel the new Bill Amount selected will only be used for that specific claim and will default back to the standard/original Usual and Customary. Click Coverage Inquiry Within a few seconds the Coverage response will appear; Accepted will provide the reimbursement for the physician and the financial responsibility for the patient. The practice is responsible for collecting the patient s financial responsibility (co-payment/deductible). This is a requirement of the PDPs/plans and CMS. Denied THIS PLAN DOES NOT ACCEPT ON-LINE CLAIMS Proceed to 7: Paper Claim Process.

5 Once Denied with a response message. The response message should instruct you with what needs to be to resubmit the claim successfully or enter the appropriate denial override information.

3 5 Once Denied with a response message. The response message should instruct you with what needs to be to resubmit the claim successfully or enter the appropriate denial override information. See Section 6 Coverage Inquiry Response Messages. Successful Coverage Inquiry the coverage inquiry is successfully completed, one of the following steps must be taken: Submit Claim: If the patient will receive the vaccine on the date the coverage inquiry was submitted, click submit. With the exception of collecting the patient s co-payment/deductible, no further action needs to be taken. The claim has been electronically submitted. Payment will be processed and forwarded to DSI/POC Management Group. DSI will reconcile the payment against submitted claim history, and forward a consolidated statement and payment each month. Cancel Claim: If the vaccine will not be administered to the patient for the date of service processed, the claim should be canceled. Once canceled no further action need to be taken. Pend Claim: If there is uncertainty as to when and/or if the patient will receive the vaccine, select Pend Claim. Pending a claim will hold the claim for 24 hours. If the patient will receive the vaccine on a different date of service, the coverage inquiry should be canceled. A new coverage inquiry should be processed for the correct date of service. At the end of the each day (See End of Day Processing), all Pending claims should be reviewed for further action. Pending claims that are not Submitted or Canceled within 24 hours, will be automatically Canceled. 6 A Note: All vaccine successfully administered requires an signature acknowledgement by the receiving patient. See Signature Log for more information. Coverage Inquiry Response Messages Coverage Inquiry may be returned as Denied, Denied with a Response Message or an Error message. Most Response Messages will identify the missing information required for successful resubmission of the claim, or will provide further explanation and instructions on steps that must be taken to resolve the problem. Some examples are provided below.

Denial: Denials can occur for multiple reasons including but not limited to: benefit coverage issues (the vaccine/medication is not covered under the patient s plan), previous administration of the

4 Denial: Denials can occur for multiple reasons including but not limited to: benefit coverage issues (the vaccine/medication is not covered under the patient s plan), previous administration of the vaccine (the patient previously received a one time use vaccine), Pre-Authorization is required. Authorization: Most plans/pdps will provide a phone number to call if an authorization is required. Once authorized, most plans will make the necessary changes to accept the claim once resubmitted. To resubmit a claim, go to Coverage Inquiry, select the patient, insurance plan, and click Coverage Inquiry. Error: Error messages are usually related to system/technical issues. If the plan/pdp s system is down, the claim will need to be submitted at a later time. 7 There Unresolved Denial/Error messages: If the Denial or Error message cannot be resolved, the claim can be printed (select Print ) and submitted by mail. See Paper Claim Process below. Paper Claim Process are two options for processing a paper claim: Option 1: The physician collects payment from the patient and provides the patient with a paper claim for submission for reimbursement from their health plan/pdp. Depending on the plan/pdp, the patient may also be required to complete a separate prescription reimbursement form provided by the plan/pdp. Physicians should be aware that plans/pdps may not reimburse patients 100% of billed charges. Many will reimburse usual and customary/ prevailing fees. Option 2: The physician submits the paper claim to the plan/pdp for reimbursement. The plan should remit payment to the physician less any co-payments or deductible due from the patient. Physicians should be aware that plans/pdps may not reimburse billed charges. Many will reimburse usual and customary/prevailing fees. Note: Processing a paper claim does not guarantee payment, and the patient s plan information must be available. The plan/pdp should be contacted prior to administration of a vaccine/medication to confirm benefit coverage.

8 Click Transaction Log on Menu,, Transaction Log The Transaction Log is a historical log of all transactions including; eligibilities performed, claims submitted, rejected, canceled and/or printed

5 8 Click Transaction Log on Menu,, Transaction Log The Transaction Log is a historical log of all transactions including; eligibilities performed, claims submitted, rejected, canceled and/or printed paper claims. The transaction log allows you to view and/or re-print any transaction (claim). Transactions can be viewed by Account, Site and Transaction Type. Transactions can also be filtered within a specified date range. To display transaction information simply select the desired options (Account, Site, Date, Status) and click Search. To print a claim, highlight the transaction desire and click Print Claim. To view the detailed transaction information highlight and double-click on the specific transaction or highlight and click on View Claim The screen will provide you with all transaction detail. To view claims submitted for payment go to; Menu> Claims Management > Claims. coverage_training_v4e.indd

Getting Started. Enter Patient Information/Check Eligibility. To perform a Coverage Inquiry, open your browser, go to

Getting Started. Enter Patient Information/Check Eligibility. To perform a Coverage Inquiry, open your browser, go to Medicare part D Coverage Inquiry Manual Getting Started To perform a Coverage Inquiry, open your browser, go to www.mytransactrx.com Click on Menu, Part D Coverage Inquiry Enter Patient Information/Check