Topics Patient Eligibility Search:  
Introduction: Patient Eligibility provides information on the 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 (PBMs) / Payers, which are generally 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 turn sends the response back to PrognoCIS. The 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 at the start of the encounter.

Requirements for Eligibility to be Fetched:
  • The patient's First Name, Last Name, Date of Birth, Gender, and ZIP Code should match with the details on the pharmacy insurance side
  • The patient should have valid insurance
  • The patient should have a 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 lowercase
    • A-Z: All alphabets in uppercase
    • 0-9: All digits from 0 to 9
    • Others: ! " # $ % & ' ( ) + , - . / : ; < = > ? @ [ \ ] _ ` { }
  • The validation for PrognoCIS-supported characters is applied to 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 the gender as Unknown, the Eligibility request is sent, but WITHOUT the patient's 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 the patient's gender.
Fields in Eligibility Info:

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

Action Buttons:

Cancel Button: Click this button to exit the Eligibility popup without saving any changes.

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

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