Eligibility Troubleshooting 101

Transcription

1 Eligibility Troubleshooting 101 Reference Guide

2 Contents Introduction... 3 Invalid/Missing Search Criteria... 3 Invalid/Missing Subscriber/Insured Name... 3 Resubmit... 5 Patient vs. Subscriber... 7 Invalid Date of Birth... 8 Invalid/Missing Subscriber/Insured ID Invalid/Missing Date(s) of Service Subscriber/Insured Not in Group/Plan Identified Tricare Change Payer Third Party Administrator OneSource Alternate Search Options Employer Lookup Customer Support

3 Introduction When a patient s insurance doesn t come back as eligible or inactive on the first try, some detective work may be required to understand why the payer was unable to return the eligibility response as expected. In Eligibility Troubleshooting 101, we will cover ways to troubleshoot some of the common payer error messages that you may encounter when verifying eligibility. ecare NEXT (ecn) offers are variety of tools to help with this detective work, including the resubmit and change payer functions. Additionally, OneSource (OS) can be a helpful resource when investigating payer error messages. Payer error messages will appear in a yellow/orange banner at the top of the MyView response in ecn and OS. Messages may vary by payer, but examples of common messages include invalid/missing search criteria and subscriber/insured not in group/plan identified. Invalid/Missing Search Criteria A yellow/orange eligibility banner that states that some of the search criteria is invalid/missing indicates that there were no matches found in the insurance company s database for the information entered. The type of invalid/missing search criteria message on a response depends upon what information the payer has deemed as invalid or missing. Specific messages include invalid/missing subscriber/insured name, patient birthdate does not match that for the patient on the database, invalid/missing subscriber/insured ID, and invalid/missing dates of service. These specifics let the user know what to look for when troubleshooting the error. Invalid/Missing Subscriber/Insured Name Certain payers require that the information submitted to them match what they have in their database exactly in order to return an eligibility response. For example, if a patient s name is listed as William in your registration system, but the payer has them listed as Bill, a payer that requires exact matches may return an invalid/missing subscriber/insured name message. 3

4 Click on the full response tab to see the full message returned and the search criteria that was used. After viewing the criteria used in the search, it may be useful to compare the name on the insurance card to the name in your registration for any discrepancies, or to check with the patient to see if they are aware of any differing or incorrect information that the payer may have on file. Hyphenated last names can be a common cause for this name discrepancy. Let s say that our patient s name is Carmen Smith-Jones. In our registration system, we have her listed as Carmen Smithjones, but upon viewing the patient s insurance card, we see that the insurance has her listed as Carmen Jones. If the payer requires exact matches, a message of invalid/missing subscriber/insured name may be returned. The payer used in the above screenshot, Sunshine State Health Plan, is a payer that requires exact matches. Let s try sending the request to the payer again, but this time, let s use the name listed on Carmen s insurance card. We ll use the resubmit button to do this. 4

5 Resubmit To retry the request using alternate criteria, click resubmit. Resubmit can be accessed from the In-Process Scripting (IPS) window, as shown in the screenshot below, or from the patient s eligibility response in ecare NEXT. A pop-up window will display the information that is being sent to the payer. The fields will be prepopulated with the information that was sent to the payer as part of the most recent eligibility request. 5

6 Make any desired changes and click submit request. Please allow a few moments for the request to process. The page will reload with the new results from the payer. If the information submitted now matches what the payer has on file in their database, the patient s eligibility response will display. 6

7 Patient vs. Subscriber An invalid name message can also appear if the incorrect family member is entered as the subscriber. When resubmitting your transaction, ensure that your patient s relationship to subscriber is correct. If the relationship is incorrect, the invalid name message may appear due the payer searching for a different family member than the one that you intended. Please note that some payers always consider the patient to be the subscriber, even in scenarios where they would historically be thought of as a dependent. For example, if a child gets insurance through their parent s employer, we would normally refer to the parent as the subscriber when talking about their insurance coverage. However, some payers consider each member to be their own subscriber, even if they are a child. 7

8 Invalid Date of Birth A message of patient birthdate does not match that for the patient on the database indicates that that the birthdate listed in your registration system for your patient does not match what the payer has on file for the patient in their system. Please note that this does not necessarily mean that the birthdate in your system is incorrect it may be the payer that has the incorrect date of birth on file. Even so, if a payer requires exact matches, your request will need to match the birthdate that the payer has in their records. The silver lining of this particular message is that it indicates that the payer does have someone in their database that is very close to the patient you are searching for it means that they ve found someone, but they re requiring an exact match before they ll return their coverage information. When faced with this message, it s a good practice to verify the date of birth with the patient. Additionally, try checking the patient s insurance card to see if it has a date of birth listed on it. If the patient provides a corrected date of birth or you find an alternate date of birth listed on the insurance card, try resubmitting the transaction by following the steps covered on page 5 of this guide. In the previous resubmit example, we saw what resubmit looks like via the IPS window. For this example, let s look at the resubmit button on the ecare NEXT webpage. Click resubmit. 8

9 For this example, let s say that while speaking with our patient, she tells us that her insurance company has her birthdate transposed. She states that she s contacted them to correct the error, but they have her birthdate listed as 04/05/68 instead of 05/04/68. Enter the birthdate provided and click submit request. Please allow a few moments for the request to process. The page will reload with the new results from the payer. If the information submitted now matches what the payer has on file in their database, the patient s eligibility response will display. 9

10 Invalid/Missing Subscriber/Insured ID Invalid/missing subscriber/insured ID indicates that the payer does not have a matching policy ID number for that patient on their end. Compare the ID number listed on the insurance card with the ID number in your registration system to ensure that the policy number was keyed in correctly. If you notice a discrepancy, use the resubmit function covered earlier in this manual to make any necessary changes and try the request again. Some payers, such as Aetna, UnitedHealthcare, and Cigna, will allow eligibility inquiries without a policy number. Other payers, such as Medicare and most Blue Cross plans, will not. For payers that do not require a policy ID, you may use the resubmit function. Delete the text in the subscriber ID (and/or patient ID) field(s) and submit your request to force the system to search without the ID number. If you are unsure if a payer requires a policy number or if the resubmit function of ecn will not allow a name search for the payer in question, you may also consider searching for the patient in OneSource. Please see the OneSource section of this guide for more information. 10

11 Invalid/Missing Date(s) of Service The invalid/missing date(s) of service message appears when a date of service was not received with the eligibility request or the date of service was outside of the date range allowed by the payer. Click resubmit. If a date of service outside of the current date is listed, this can indicate that the date is outside of the range allowed by that payer. In the example below, a date of service of August 26, 2015 was entered. However, Medi-Cal s date of service rules state that requests can only be up to one year in the past, or future dates up to the end of the current month. Therefore, a date in 2015 is invalid. Enter a date that meets the payer s date of service requirements and click submit request. Please note that date of service requirements vary by payer. To verify date of service requirements for a specific payer, please consult the X12 Companion Guide (5010) Eligibility available on the User Info page in OneSource. 11

12 Please allow a few moments for the request to process. The page will reload with the new results from the payer. Subscriber/Insured Not in Group/Plan Identified A message of subscriber/insured not in group/plan identified indicates that the payer is aware of the patient, but is unable to give full details regarding the patient s eligibility. This generally happens when the patient s insurance is through a different payer that is somehow connected or affiliated with the payer that received the eligibility request. This message commonly occurs with when Tricare and Tricare for Life plan codes are used interchangeably, or when the plan is through a Third Party Administrator. Tricare This message is common when running eligibility for Tricare. Tricare for Life and Tricare are two individual payers with separate payer databases. If an eligibility request that should go to Tricare is sent to Tricare for Life (or vice versa), a message of subscriber/insured not in group/plan identified will be returned. Use the change payer function to try the request with the other payer. Change Payer Use the change payer function to switch to another payer. A new window will open and prompt you to select another payer. Make the applicable selections from the dropdowns, and click switch payer. A resubmit window will appear for the selected payer. Click submit request to check eligibility for the selected payer. Please allow a few moments for the request to process. 12

13 A new tab will be created for the new payer. Click the new tab to view the results from your latest eligibility request. Third Party Administrator Sometimes, a patient might have insurance through a Third Party Administrator (TPA) that utilizes the network of a larger payer, such as UnitedHealthcare. In these cases, the patient s insurance card might feature the logo of that larger payer, and a registrar may try to search for eligibility with that payer. However, the card will most likely carry the logos or names of one or more smaller payers. The larger payer is aware that the patient exists, but is unable to provide the eligibility details. The response will generally contain information about the payer that should be contacted for eligibility information. If it is a payer that provides benefits in ecare NEXT, use the change payer function described above to resubmit the request with the desired payer. However, some TPAs may not provide electronic benefits. In these cases, use the information listed to contact the payer for benefit information. 13

14 OneSource Certain features of OneSource may come in handy when diagnosing payer eligibility error messages. Many payers in OneSource allow users to select which search option to use for their inquiry, which may allow users to work with the information that they do have as they try to fill in the missing pieces of the eligibility puzzle. OneSource also has an Employer Lookup feature that can offer a promising starting point when a patient with employerbased coverage is unsure of their insurance provider. Alternate Search Options When searching for eligibility via OneSource (OS), users will be asked to select a search option from a dropdown menu. Search options will vary by payer, and are based on individual payer requirements. In the example below, this particular payer allows us to search using the patient s name and date of birth. If you did not have the patient s policy ID number, you could use this search option to search for your patient. The resulting eligibility response will display the policy number on file with the payer. Please remember to update your registration with the correct policy number if appropriate. 14

15 Employer Lookup OneSource s Employer Lookup tool is a searchable database of employer insurance plans. This data is indexed from the group name field of the transactions that are run at your facility. For example, if you run an Aetna transaction where the patient s group name is LargeMart, this information will be automatically added to the Employer Lookup for future reference. This data can be leveraged when a patient presents at your facility without their insurance information. The patient may state that they get their insurance through their employer, but they are unsure of who their insurance company is. Click Employer Lookup, which is located on the left side of the page under the Tools category. 15

16 Type the employer name in the search field. As you type, matching results will automatically populate below. In the following example, Group Number 3 appears to offer their employees Cigna insurance. Click on the payer name to be redirected to the submission form for that payer. If the payer allows for inquiries without a policy ID, use that option to search for your patient. Please note that the Employer Search is not an inclusive list of all employers. It is limited by the group names that have been present on previous eligibility transactions run by your facility. Customer Support For additional inquiries, please contact Experian Health Customer Support. Customer Support is available 24/7. Customer.Support@ExperianHealth.com Phone: (866) Experian Health Product Dashboard: Payer Status: 16