Insurance Eligibility Basics

Transcription

1 Insurance Eligibility Basics Overview Introduction This lesson provides an overview of the insurance eligibility verification process, why we verify eligibility, and how we verify eligibility. Verifying that we are billing the correct payor is crucial for the School of Medicine to be reimbursed for services provided. If the claim is sent with the wrong information, a rejection is received from the payor and delays reimbursement. Objectives Upon completion of this lesson you should: Understand the basics of insurance eligibility Understand how eligibility is verified Know the key eligibility verification information and where it is stored Be able to identify verification fields in the Plan/FSC follow-up questions Prerequisites Prior to this lesson you should have completed: P-Plan/FSC Assignment 1

2 What is Insurance Eligibility Verification? Insurance eligibility verification indicates the payor has acknowledged that a patient is enrolled with the payor on the date verified. Eligibility verification does not confirm the School of Medicine has assigned the correct FSC/Plan for the patient. FSC/Plans are developed by the School of Medicine for the IDX system. Once payor eligibility information is available, you must review that information to determine if the correct FSC/Plan is assigned. Why does Washington University verify eligibility? The School of Medicine is committed to obtaining correct insurance information as early in the Patient Financial Services (PFS) process as possible. Eligibility verification is a critical step in accomplishing this goal. Correct insurance information contributes to optimizing reimbursement with payment as quickly as possible. What is key eligibility verification information and where is it stored? Eligibility verification information is stored at the visit level in the plan follow-up questions and at the registration level in the FSC follow-up questions. The three primary fields that store verification information are: 1. Eligibility Verification Date 2. Eligibility Status 3. Eligibility Verification Source 2

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4 How is Eligibility Verified? There are four sources of eligibility verification at the School of Medicine. 1. Manual Verification: Manual contact with the payor. Phone with payor Web with payor Documentation from payor Employer 2. Recent Payment Verification: Most recent date of service for which payment was received from the payor. 3. ampi/quovadx Interface: Electronic exchange of demographic and insurance information, including verification dates, from BJH and SLCH. 4. e-commerce: e-commerce provides electronic links between healthcare organizations, such as the School of Medicine, and payors to verify insurance eligibility direct from the payor s database. 4

5 Manual Verification Manual verification is the process of manually contacting the payor to verify that a patient is enrolled with that payor on the date verified. The methods of manual verification include: Phone with payor Web with payor Documentation from payor Employer Each department independently decides in what situations, if any, they will manually verify eligibility with the payor. When manually verifying eligibility, you must enter the verification date, an eligibility status of active or inactive, verification source, and your username. NOTE: If the patient s coverage is not active as a result of manual contact with the payor, steps must be taken to determine the patient s correct insurance. Tips for Manual Eligibility Verification: When manually verifying benefits collect the following information: Plan type (ex. PPO, Open Access) Plan name as it appears on the patient identification card Effective date Eligibility status (active/inactive) o If inactive, termination date TPA name and phone number 5

6 Eligibility Status The eligibility status field documents the patient s enrollment status with the payor on the date verified. The eligibility status is stored in the follow-up questions. There are five possible eligibility status responses: Active: Patient is enrolled with the payor on the date of the verification. o All sources of eligibility verification (ampi/quovadx Interface, Recent Payment, Manual, and e-commerce) use the eligibility status of ACTIVE. o An active eligibility status does not mean that the School of Medicine s FSC/Plan is correctly assigned. It only means that the patient is enrolled with the payor on that date. Inactive: Patient is found in the payor s database but is not active at the time of the request. In addition, e-commerce returns other eligibility status responses as provided by the payor. Rejected: Payor is unable to locate the patient in their database. Mixed: Patient is active for some benefits, but inactive for others. No Response: The payor s system may be down. If the payor s system comes back on-line within the same day, you may receive a response. Pending: Waiting for a response from the payor. 6

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8 Recent Payment from Payor This source indicates that a recent payment has been received. The date of service for which the last claim was paid by the payor associated with the FSC/plan will default into the follow up questions. 8

9 ampi/quovadx Interface This source indicates that BJH or SLCH has verified eligibility. The date of the most recent BJH or SLCH verification will default into the follow up questions. 9

10 e-commerce IDX e-commerce services provide electronic links between healthcare organizations, such as the School of Medicine, and payors. When eligibility is verified through e-commerce, additional information such as: co-payment amounts, primary care physician, effective and termination dates, benefit information, and dependent coverage are returned. 10

11 Lesson Summary In this lesson you learned: The basics of insurance eligibility How eligibility is verified Key eligibility verification information and where it is stored How to identify verification fields in the Plan/FSC follow-up questions 11