Topics Patient Eligibility Search:  
Introduction: Patient's Eligibility provides information on patient’s Pharmacy Benefit Insurance. It consists of the Payer Name, Patient information, Plan Name, Pharmacy type, Benefit Effective Date, etc. Eligibility is fetched from the Pharmacy Benefit Managers (PBM) / Payer, which are generally the Insurance companies. In PrognoCIS, the Eligibility request is sent to Surescripts which then sends it to the PBMs/Payers. Then the PBMs/Payers send an Eligibility response consisting of all the details of the patient’s Insurance and Pharmacy to Surescripts, which in turns sends the response back to PrognoCIS. Fetching of Eligibility in PrognoCIS depends on the value of the property rx.surescript.checkeligibilityatencstart. If this property is On, then the Eligibility of the patient for Pharmacy Benefits is fetched on the start of encounter.

Requirements for the Eligibility to be fetched:
  • Patient’s First Name, Last Name, Date of Birth, Gender and ZIP code should match with details on the pharmacy insurance side
  • Patient should have valid Insurance
  • Patient should have pharmacy benefit included in the health insurance
Eligibility Request Checklist:
  • The fields sent in the eligibility request can consist of the following special characters:
    • a-z: All alphabets in lower case
    • A-Z: All alphabets in upper case
    • 0-9: All digits from 0 to 9
    • Others: ! " # $ % & ' ( ) + , - . / : ; < = > ? @ [ \ ] _ ` { }
  • The validation for PrognoCIS supported characters is applied on the following fields sent in the Eligibility request:
    • Encounter Attending Provider fields: Title, First name, Middle name, Last name
    • Patient fields: Chart No, First name, Middle name, Last name, Add Line 1, Add Line 2, City
  • If an Eligibility request is sent to Surescripts for a Patient with gender as Unknown, the eligibility request is sent, but WITHOUT patient gender. However, when a patient's gender in the patient's records in PrognoCIS is either Male or Female, then the Eligibility request is sent WITH patient gender.
Fields in Eligibility Info:

The Eligibility popup consists of Elibility Info table where all the PBMs/Payers are listed. The user is required to select any one applicable patient Eligibility by selecting the radio button associated with it. As soon as an Eligibility is selected, the Eligibility popup is closed.
Following are the fields that are displayed for each Eligibility:
  • Payer Name
  • Subscriber Name
  • Patient Name
  • Patient DOB
  • Gender
  • Address
  • Plan Name
  • PCN
  • Mail fullfillment Pharmacy Name
  • Unique Id
  • Card Holder Name
  • Primary Payer Name (COB)
  • BenefitEffectiveDate
  • Pharmacy table: Pharmacy Type, Pharmacy Name, Supported, Out of Pocket Amt., Insurance

Action Buttons:

cancel button: Click on this button to exit the Eligibility popup without saving any changes done.

retry button: If patient's Eligibility is not fetched and an error message is displayed, only then the retry button is displayed. The user needs to click on this button to send the Eligibility request again.

See Also: Prescription | Real Time Formulary and Prescription Benefit Information