eauthorization Providers e-authorization Application on eclaimlink SEPTEMBER 2016 in partnership with

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1 Providers e-authorization Application on eclaimlink SEPTEMBER 2016 in partnership with 1

2 Table of Contents Getting Started 3 Registration 4 Logging In 5 Prior Request Form 6 Eligibility 7 Submit Prior Request Form 9 Prior Request Form 10 Authorization 10 Submit Prior Request Form 15 Prior Request Form 10 Error Alert Example 16 Transactions Summary Table 18 Summary Table 18 Prior Request Details 20 Actions 24 Closing the window \ Printing 24 Response Interpretation 25 Transactions List 31 Filter Transactions 31 List Content 32 Exit the Page 33 Support 34 eclaimlink is the eclaim project of the Dubai Health Authority implemented in partnership with Dimensions Healthcare with the objectives of establishing a unified standard healthcare language communicated across the emirate, implementing a unified structured communication schema, providing a centralized health data tracking system, facilitating eclaim financial and clinical information between payers, providers, patients & authorities. Empowering the Dubai Health Authority with the needed information to organize, strategize, and optimize the healthcare setting in Dubai. The eclaimlink portal is intended to manage eclaims and health data. In addition, it will serve to connect all the healthcare community of Dubai and through its many anticipated modules will raise the quality of care, enhance efficiency, and reduce mistakes, fraud and abuse in the Emirate of Dubai. Visit for more information. 2

3 Getting Started Accessing the eclaimlink system requires that your facility to be equipped with a computer and an internet connection. To get started, open your internet browser and navigate to the following website: You will then be directed to the eclaimlink main website. On the upper left corner of the page, you will find a login form, click to register your facility if you are a new user. If already registered on eclaimlink please enter your facility s username and password, then click Log In. Then skip page 4 and go directly to page 5 of this manual. 3

4 Registration If you are a new user, to register you need to have a valid license with one of the health authorities or the MOH (ministry of health) in the UAE. Register your licensed pharmacy on eclaimlink by clicking Click to register in the login section on the main page. If you are part of a group of pharmacies, each one needs to be registered on eclaimlink. You must only use the account of the facility in which you are practicing. Enter all requested information in the form. After validation for your ID is done, your account shall be activated and you should receive a notification through the you registered with. 4

5 Logging In After logging in from the login section on the main page, click on the Applications button to open the Applications page. Locate the New Applications box and click Login to eauthorization system. 5

6 erxphysician Prior Request Form This page contains the e-authorization form to be filled out. Important information to remember when filling out this form: Required fields are marked with an asterisk* Pre-defined list For all fields that have a pre-defined list, you can start typing a few characters in the field and the system will auto-generate a drop-down list of suggested values to choose from. 6

7 Prior Request Form The Prior Request Form contains two transaction types: Eligibility and Authorization. Eligibility Transactions that check whether the patient is an eligible member within its Insurance Company managed portfolio. It only validates the member ID and does not provide an authorization of a specific service. Authorization Transactions which include eligibility checks, as well as diagnosis and activities details for a specific service. The provided authorization for these requests take into consideration member eligibility, coverage, limits, and clinical reviews. 7

8 Prior Request Form ELIGIBILITY To know if the card holder is eligible the facility needs to request the following from the patient and enter them in their appropriate fields in the system: Transaction Type: Eligibility or Authorization Encounter Type: Pre-defined list - Select type of encounter from pre-defined dropdown list Date ordered*: Date of submission of transaction Patient Name: Patient name (only for internal tracking purposes) Patient ID: Patient file number at the facility Contact Number: Patient mobile number Member ID*: Unique reference ID of the patient. This can be the insurance ID as shown on the patient s insurance card, or another unique identifier of the member. Plan(Payer/Receiver)* : Pre-defined list - The patient correspondent plan at the insurance company. Emirates ID*: National Emirates ID or select reason if not available. 8

9 Prior Request Form SUBMIT PRIOR REQUEST FORM: Request Authorization Click this button located at the bottom of the page to request for authorization on the patient s eligibility from their insurance company, after completion of the prior request form. When you click on this button, a small message is displayed on the screen confirming that your request was sent, saying Successful Request. Click OK to acknowledge this. The system will line up the prior requests in the order they were submitted along with their relevant information in the queue of submitted transactions on the right pane. The status of the request will initially be Pending until a response from the Insurance Company is received. Clear Alternatively, click this button located at the bottom of the page to clear the content of the prior request form. 9

10 Prior Request Form AUTHORIZATION To request an eauthorization you should complete the information in the following 3 sections: Patient & Encounter Information Diagnosis Information Activities Information Only when selecting the transaction of type Authorization will the user be able to view the complete form including its three sections. 10

11 Prior Request Form Section 1: Patient & Encounter information Please see page 7 for the definitions of the fields for this section. This fields for this section are the same as found in the Eligibility transaction type. 11

12 Prior Request Form Section 2: Diagnosis information Type*: Primary, Admitting, or Secondary. Only one Primary Diagnosis or Admitting is allowed, but you can add several Secondary diagnosis. Diagnosis Code with Description*: Pre-defined list - Enter the ICD10-CM code if you know it or enter keywords of the diagnosis description you are seeking and the system will show you a short list of related diagnosis descriptions and codes to select from. The more specific, the better the return results from the system. 12

13 Prior Request Form Section 3: Activities information Type: Pre-defined list - Type of the activity: CPT (for procedures including operations, labs and radiology), Dental, Drug, Service (including consultation), and HCPCS (consumable and disposables) Activity*: Pre-defined list - Enter code or search by entering a keyword to search for the needed code or description Start: Start date of the activity /service Quantity*: The number of Activities served Net*: The net charges billed by the provider to the insurance company for this activity Clinician*: Pre-defined list - Physician supervising the activities in this encounter 13

14 Prior Request Form Section 3: Activities information Observation(s) are part of activities and are not mandated except in certain cases. This must be exactly same as reported by treating doctor. Type: Pre-defined list - One of the listed types to be selected: LOINC, Text, File, Universal Dental, Financial, Grouping, ERX, Result. Code (Pre-defined list), Value and Value Type vary depending on the observation type and nature of data. 14

15 Prior Request Form SUBMIT PRIOR REQUEST FORM: Request Authorization Click this button located at the bottom of the page to request for authorization on the activities from the patient s insurance company after completion of the prior request form. When you click on this button, a small message is displayed on the screen confirming that your request was sent, saying Successful Request. Click OK to acknowledge this. The system will line up the prior requests in the order they were submitted along with their relevant information in the queue of submitted transactions on the right pane. The status of the request will initially be Pending until a response from the Insurance Company is received, in which the status will then be changed to Received. Clear Alternatively, click this button located at the bottom of the page to clear the content of the prior request form. 15

16 Prior Request Form ERROR ALERT EXAMPLES Invalid Clinician: Error may encounter if Clinician ID/Name is not selected from the drop down list or manually entered in the Clinician field. Action to be taken: Clinician ID/Name should be selected from drop down list. 16

17 Prior Request Form Invalid Activity: Error may encounter if Activity Type is added prior to attaching a file Action to be taken: Activity Type should be selected prior to attaching any file. Attachment requires PDF format and only maximum of 5MB is allowed. 17

18 Transactions Summary Table SUMMARY TABLE: On the right side of the Prior Request Form is a small table containing some information related to the last 5 transactions sent. Details included in table: 1. Member ID Unique reference ID of the patient receiving the e-authorization. This can be the insurance ID as shown on the patient s insurance card, or another unique identifier of the member. 2. Authorization ID A unique number generated by the system for each authorization request. 3. Status A small message displaying the current status of each authorization request. 4. Type Eligibility or Authorization 18

19 Transactions Summary Table 5. Action When you receive a response from the payer on the authorization request, you have the option to take one of the following actions: Cancel The Prior Request sent will be fully cancelled. Edit The original Prior Request will be cancelled and a new Prior Request form will appear autopopulated with the previously entered information, to be resubmitted. 19

20 Transactions Summary Table PRIOR REQUEST DETAILS: Click on Show details also located in the Action column to view the details for each submission. The Details include the following: 1. General Details: Transaction ID System-generated transaction ID number Transaction Type Eligibility or Authorization Encounter Type Select type of encounter from pre-defined dropdown list Date ordered Date of transaction submission Patient Name Patient name (only for internal tracking purposes) Patient ID Patient file number at the facility 20

21 Transactions Summary Table PRIOR REQUEST DETAILS: Member ID Member insurance ID as exactly provided on Insurance Card Emirates ID National Emirates ID Request time Time of transaction submission Response Time Time when received the payer response Download Time Time when the transaction was downloaded Cancel Time Time when transaction was cancelled Insurance Plan Patient s insurance plan (includes payer and receiver) Authorization ref# (ID Payer) Number generated by the payer system for the Authorization Result The answer of the inquiry Yes or No 21

22 Transactions Summary Table PRIOR REQUEST DETAILS: Start Date and time in which activity started End Date and time in which activity ended Limit Identifies Authorization Limit Denial The denial code if the claim is denied by the payer Comments Reason(s) for denial would be included here Actions- Advised transaction status 22

23 Transactions Summary Table 2. Diagnosis Details: A list of the Diagnoses. For each entry the type is listed (as primary or secondary) in addition to the code and description 3. Activities: A list of all the activities and their related information. The status of each activity is shown here; whether it was accepted or rejected by the insurance company 23

24 Transactions Summary Table ACTIONS Same action buttons as found on the summary table, to allow actions to be taken from this screen as well CLOSING THE WINDOW \ PRINTING To close this window, click on Close located in the top right of the window, or use the Esc Key on the keyboard. To print this page, click on Click to Print this Screen also located in the top right of the window. 24

25 Response Interpretation Below is a list of the denial codes and their descriptions that will be used by the payers on the activity level in order to justify any rejection DENIAL CODE DENIAL DESSCRIPTION ELIG-001 ELIG-005 ELIG-006 ELIG-007 AUTH-001 AUTH-003 AUTH-004 AUTH-005 AUTH-006 AUTH-007 AUTH-008 AUTH-009 Patient is not a covered member Services performed after the last date of coverage Services performed prior to the effective date of coverage Services performed by a non-network provider Prior approval is required and was not obtained Prior Authorization Number is invalid Service(s) is (are) performed outside authorization validity date Claim information is inconsistent with pre-certified/authorized services Alert drug - drug interaction or drug is contra-indicated Drug duplicate therapy Inappropriate drug dose Prescription out of date 25

26 Response Interpretation DENIAL CODE AUTH-010 AUTH-011 BENX-002 BENX-005 CLAI-007 CLAI-008 CLAI-009 CLAI-010 CLAI-011 CLAI-012 CLAI-014 CLAI-017 DENIAL DESCRIPTION Authorization request overlaps or is within the period of another paid claim or approved authorization Waiting period on pre-existing / specific conditions Benefit maximum for this time period or occurrence has been reached Annual limit/sublimit amount exceeded Claim is a work-related injury/illness and thus the liability of the employer Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay Date of birth follows the date of service Date of death precedes the date of service Inpatient admission spans multiple rate periods. Resubmit separate claims Submission not compliant with contractual agreement between provider & payer Claim not compliant with Resubmission type (used only for resubmissions) Services not available on direct billing 26

27 Response Interpretation DENIAL CODE CLAI-018 CODE-010 CODE-012 CODE-013 CODE-014 CODE-015 DUPL-001 DUPL-002 MNEC-003 MNEC-004 MNEC-005 MNEC-006 DENIAL DESCRIPTION Claims Recalled By Provider Activity/diagnosis inconsistent with clinician specialty Encounter type inconsistent with service(s) / diagnosis Invalid principal diagnosis Activity/diagnosis is inconsistent with the patient's age/gender Activity/diagnosis is inconsistent with the provider type Claim is a duplicate based on service codes and dates Payment already made for same/similar service within set time frame Service is not clinically indicated based on good clinical practice Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities Service/supply may be appropriate, but too frequent Alternative service should have been utilized 27

28 Response Interpretation DENIAL CODE NCOV-001 NCOV-002 NCOV-003 NCOV-025 PRCE-001 PRCE-002 PRCE-003 PRCE-006 PRCE-007 PRCE-008 PRCE-009 PRCE-010 DENIAL DESSCRIPTION Diagnosis(es) is (are) not covered Pre-existing conditions are not covered Service(s) is (are) not covered Service(s) is (are) not performed (used after audit) Calculation discrepancy Payment is included in the allowance for another service Recovery of Payment Consultation within free follow up period Service has no contract price Multiple procedure payment rules incorrectly applied Charges inconsistent with clinician specialty Use bundled code 28

29 Response Interpretation DENIAL CODE PRCE-011 TIME-001 TIME-002 TIME-003 COPY-001 SURC-001 SURC-002 SURC-003 SURC-004 SURC-005 SURC-006 SURC-007 DENIAL DESSCRIPTION Discount discrepancy Time limit for submission has expired Requested additional information was not received or was not received within time limit Appeal procedures not followed or time limits not met Deductible/co-pay not collected from member Sever drug - drug interaction Sever drug - age contraindication Sever drug - gender contraindication Sever drug - diagnosis contraindication Sever procedure\service - diagnosis contraindication Sever procedure\service - drug contraindication Sever procedure\service - procedure contraindication 29

30 Response Interpretation DENIAL CODE PRCE-011 TIME-001 TIME-002 TIME-003 COPY-001 SURC-001 SURC-002 SURC-003 SURC-004 SURC-005 SURC-006 SURC-007 SURC-008 WRNG-001 DENIAL DESSCRIPTION Discount discrepancy Time limit for submission has expired Requested additional information was not received or was not received within time limit Appeal procedures not followed or time limits not met Deductible/co-pay not collected from member Sever drug - drug interaction Sever drug - age contraindication Sever drug - gender contraindication Sever drug - diagnosis contraindication Sever procedure\service - diagnosis contraindication Sever procedure\service - drug contraindication Sever procedure\service - procedure contraindication Serious safety issue with drug dose Wrong submission, receiver is not responsible for the payer within this transaction submission. 30

31 Transactions List This is a more detailed table containing a list of the submitted transactions. Navigate to this page by clicking on the Transactions List icon located on the top left of the page that contains the Prior Request form. FILTER TRANSACTIONS You can search for transactions using any of the following search criteria to filter your results: ID System-generated ID for the submitted transaction ID Payer Member ID Plan Insurance plan for the patient From Choose a date from which to begin the search (select a date from the drop-down calendar) To Choose a date at which to end your search results (select from the drop-down calendar) Status Choose from the pre-defined set of authorization statuses from the drop-down list When finished entering the search criteria click on the Filter icon. 31

32 Transactions List LIST CONTENT The Transactions List contains the following information for each submitted prescription: 1. Member ID 2. ID Transaction ID generated automatically by the system using the following format: (Facility ID_PayerID_unique number auto generated by the system). 3. Transaction Date Date and time that the transaction was submitted to the DHPO. 4. Insurance Plan 5. ID Payer ID assigned by the payer for the authorization 32

33 Transactions List 5. Status current status of the transaction. 6. Response Time Time it took for the Payer to send the eauthorization response 7. Type Eligibility or Authorization 8. Username Username of the facility on eclaimlink 9. Details Click on the Show Details icon to view further detail on the transaction 10. My Action Shows the action that was taken: Pending no response yet from payer Cancelled This indicates that you have cancelled the transaction after receiving a response from the Payer. You can click on the request again icon to refill the prior request form with the PriorRequest details and request for authorization again Eligible / Ineligible Eligibility response from payer was received and result is displayed here. You have the option to cancel or edit the prior request form Authorized Full / Authorized Partial / Authorized Rejected Authorization response from payer was received and result is displayed here. You have the option to cancel or edit the prior request form EXIT THE PAGE To exit this page and return to the Prior Request form, click of the Prior Request button located on the top left side of this page. 33

34 Support The eclaimlink System is a user-friendly platform built around the true needs of payers, providers, and regulators in the United Arab Emirates. If you have any inquiries, please call us at: Dimensions Healthcare Contact Call Center Failure to access system, login issues, functionality related inquiries, etc support@eclaimlink.ae 34