PrognoCIS Help: Insurance Eligibility

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Introduction: Click on the Eligibility button present on the Patient Insurance screen to invoke Insurance Eligibility popup. On clicking this button, the system checks if an Eligibility was fetched for the current date. If an Eligibility was fetched for the current date then the latest response which was fetched earlier for the day will be displayed, if the Eligibility was not fetched for the current date, the system first fetches the eligibility on click of the Eligibility button and then displays it. Each response fetched is displayed in the list box with the Date, Time and Timezone. In case, the Eligibility was fetched for the current date, however the user wants to re-fetch Eligibility, then the user can click on the Fetch Eligibility icon provided on the top left corner of the popup to fetch the response again. We assume that the Eligibility button is enabled when the Eligibility setup is done for ClearingHouses. Ex - TriZetto/Gateway, SecureConnect or Relay Health.

Following are the fields/columns displayed on the Insurance Eligibility popup:

Fetch New Eligibility: Click on the Fetch New Eligibility icon to re-fetch new Eligibility details for an Insurance for the current date. On clicking this icon, the Insurance Eligibility popup gets refreshed with the latest Eligibility response for current Date, Time and Time Zone. The details obtained on fetching Eligibility get added in the tabs for Patient Information and Benefit Information. The Eligibility is fetched in HTML format for TriZetto ClearingHouse.

Eligibility Request/Response Date: The Eligibility Request/Response Date dropdown displays the Date, Time and Time Zone at which the Insurance Eligibility was fetched. For every newly fetched Eligibility, the value in the dropdown is automatically set to the Date, Time and Time Zone for which it has been fetched. The user can also choose to select any previous data from the dropdown to view its details.

Demographic Updates: Clicking on the Demographic Updates icon invokes a Demographic Details pop up displaying comparison of Demographic information of the Patient. The Demographic Details popup is provided with two tabs - Patient and Subscriber. This popup displays if there is a mismatch between PrognoCIS Details and Eligibility Details. Users having the role EligibilityDemographicsUpdate assigned can update the mismatched information in PrognoCIS or ignore it till next Eligibility is fetched.

Eligibility As On: The Date on which the Eligibility was fetched is displayed here in MM-DD-YYYY format.

Note:The Submitted By, Submission Date, Submitted Type and Trace Number are specific to the clearinghouse hence this information is populated as received from the clearinghouse.

Individual Eligibility Response for: The details for whom the Eligibility is fetched is displayed here. Response statuses such as Active Coverage, Rejected, Inactive or Others can be displayed here.

Patient: The First and Last Name of the Patient are collectively displayed here in bold reddish orange font color.

DOB: The Date Of Birth of the Patient is displayed here in MM/DD/YYYY format.

Insured ID: The Policy No. or Subscriber ID of the Patient Insurance is displayed here.

Plan Begin Date: The Date when the Insurance Plan became effective is displayed here.

Plan End Date: The Date when the Insurance Plan came to an end is displayed here.

Service Date: The Date range of the first time the Eligibility was fetched and the last time the Eligibility was fetched are displayed here.

Two tabs are available to display Patient and Benefit related information for TriZetto ClearingHouse, these tabs are -
Patient Information: The Patient Information tab is selected by default on the Insurance Eligibility popup. This tab displays information regarding Patient, Provider and Payer. For Insurance with Subscriber Relation other than Self, Subscriber band is also displayed.

Patient: On clicking the Patient band present on the Patient Information tab, details such as Name of the Patient, Insured ID, Sex, DOB and Group # are displayed. Name displays the Name of the Patient. Insured ID and Group # display the Policy No. or Subscriber ID of the Patient's Insurance. Sex displays the initials for Male, Female or Unknown as M, F or U. DOB displays the Date Of Birth of the Patient in MM/DD/YYYY format.

Subscriber: On clicking the Subscriber band present on the Patient Information tab, details such as Name, Insured ID and Address of the Subscriber is displayed.
Provider: On clicking the Provider band present on the Patient Information tab, details such as Name of the Provider, Health Care Financing Administration National Provider Identifier are displayed. Name displays the name of the Attending Doctor. Health Care Financing Administration displays the 10-digit NPI (National Provider Identifier) number.

Note:

When the Eligibility is fetched for an Insurance having Invalid/Missing Provider Identification, then a message, Rejected: Invalid/Missing Provider Identification - Please Correct and Resubmit is displayed in red font color above the Patient Information and Benefit Information tabs. The same message can also be seen under the Provider subsection.

Payer: On clicking the Payer band present on the Patient Information tab, details such as Payer Name and Payor Identification are displayed. Payer Name displays the Name of the Insurance for which the Eligibility is fetched and Payor Identification displays the Eligibility Payor ID.

Note:

When the Eligibility is fetched for an Insurance having a Payer that does not offer Eligibility then a message, Your request could not be processed. This payer does not offer eligibility. Please contact TriZetto Provider Solutions at 1-800-556-2231. is displayed in red font color above the Patient Information and Benefit Information tabs. The same message can also be seen under the Payer subsection.

Benefit Information: The Benefit Information tab shows the actual Eligibility details in subsections like Active Coverage, Co-Insurance, Co-Payment, Deductible and Benefit Description Etc. When the Eligibility request is not processed, a band Cannot Process is displayed on the Benefit Information tab. On clicking this band, columns for Coverage Level, Service Type, Insurance Type, Description, Amount, Authorization, New Indicator and Procedure Code along with a Message InvalidPayerID are displayed.

Note: By default, all the sections in both the tabs are collapsed (not expanded). The user is required to click on a specific row for that section data to be displayed. Ex: Copay, Deductible, etc.

Three tabs are available to display Patient and Benefit related information for Secure Connect ClearingHouse, these tabs are -
Patient Information (Beta view): The Patient Information (Beta view) tab is selected by default on the Insurance Eligibility popup. This tab displays information regarding Patient, Provider and Payer. For Insurance with Subscriber Relation other than Self, Subscriber band is also displayed.

Patient: On clicking the Patient band present on the Patient Information (Beta view) tab, details such as Name of the Patient, Relationship to insured, Insured ID, Sex, DOB, Address Group #, Plan Sponsor, Health Insurance Claim are displayed. Name displays the Name of the Patient. Relationship to insured might display Self, Spouse, Parent, etc. Insured ID display the Policy No. or Subscriber ID of the Patient's Insurance. Sex displays the initials for Male, Female or Unknown as M, F or U. DOB displays the Date Of Birth of the Patient in MM/DD/YYYY format, Address displays Residence of the Patient. Group #, Plan Sponsor and Health Insurance Claim shows more plan related information.
Subscriber: On clicking the Subscriber band present on the Patient Information (Beta view) tab, details such as Name, Insured ID and Address of the Subscriber is displayed.
Provider: On clicking the Provider band present on the Patient Information (Beta view) tab, details such as Name of the Provider, Health Care Financing Administration National Provider Identifier are displayed. Name displays the name of the Attending Doctor. Health Care Financing Administration displays the 10-digit NPI (National Provider Identifier) number.
Payer: On clicking the Payer band present on the Patient Information (Beta view) tab, details such as Payer Name and Payor Identification are displayed. Payer Name displays the Name of the Insurance for which the Eligibility is fetched, and Payor Identification displays the Eligibility Payor ID.

Benefit Information (Beta view): The Benefit Information (Beta view) tab shows the actual Eligibility details in subsections like Active Coverage, Co-Insurance, Co-Payment, Deductible and Benefit Description, Etc. The subsections displayed might differ as per plan of Insurance. When the Eligibility request is not processed, a band Cannot Process is displayed on the Benefit Information (Beta view) tab. On clicking this band, columns for Coverage Level, Service Type, Insurance Type, Description, Amount, Authorization, New Indicator and Procedure Code along with a Message InvalidPayerID are displayed.

Note: By default, all the sections in both the tabs are collapsed (not expanded). The user is required to click on a specific row for that section data to be displayed. Ex: Copay, Deductible, etc.

Patient/ Benefit Information Text View: The Patient/ Benefit Information Text View tab shows the information displayed in Patient Information (Beta view) and Benefit Information (Beta view) tabs but in Text Format.

Note:

Historically fetched Insurance Eligibility records for Secure Connect ClearingHouse continue to be displayed in Text Format.
For cases with error AK9 Functional Group Status: Rejected, Validation Message, Could not fetch Eligibility is displayed.

Action Buttons:

PRINT: Click on the PRINT button to print the Eligibility details in PDF format. If subsection details to be printed are collapsed, then on click of the PRINT button, the same gets printed hence the User is required to expand the subsections by clicking on the respective band that needs to be displayed in the printed document. Only information from one tab i.e., the selected tab is printed at a time.

CANCEL: Click on the CANCEL button, to cancel the changes and close the Insurance Eligibility popup.

Note: After the user fetches the Insurance Eligibility one or more times and closes the popup as well as the Patient Insurance screen, on navigating back to the Patient Insurance, a check mark is displayed on the Eligibility button.