Check Eligibility

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About Check Eligibility

Using the Check Eligibility functionality, the licensed Online Eligibility users can submit
on-demand requests for a patient's eligibility verification.

The Check Eligibility function is available from the toolbar in the Patient component by clicking the Check Eligibility button .

When you click the Check Eligibility button, the application creates an XML file with the required patient information and sends the eligibility verification request to the eligibility vendor clearinghouse for transmission to the patient's payers. The eligibility request for a single patient within the Netsmart Homecare application is performed according to the following procedure:

1.	The application defines patient payers from the Payers window (Patient>General>Payers).

The application checks if payer's insurance company or insurance code is set up for Online Eligibility in Administration>Configuration>Organizations>Online Eligibility. If neither insurance company nor insurance code of the payer is set for eligibility verification, a message appears alerting you that the patient payers are not set up for Online Eligibility verification.

3.	The Patient Eligibility Submit Requests Dialog opens, where you can select the payers for which the eligibility request should be sent.

4.	The eligibility request is created and sent to a clearinghouse.

According to the settings in the Online Eligibility window, the application captures necessary information from the Netsmart Homecare database and creates an XML file. After the request is sent, the eligibility vendor matches patients based on the fields that are completed in the request file. There are no required patient data fields in this file.

Edit Service Type Code Dialog

You can access this dialog while preparing eligibility requests either from the Patient or from the Transactions component.

>	Patient>Check Eligibility>Patient Eligibility Submit Requests

>	Transactions>Online Eligibility>Show Matching Results>Matching Patients

On any of those windows, select the Display Service Type Code Details check box and then click Edit. The Edit Service Type Code dialog opens, where you can change existing or add new service type codes for the selected payer to be sent in the eligibility request.

There is a defined set of service type codes which you can select for eligibility request in the Service Type Code drop-down list (the same as in Administration>Configuration>Organizations>Online Eligibility).

Each service type code requires an NPI number to be associated to. All NPI numbers available for the selected payer are available for selection in the NPI drop-down list (payer NPI numbers are set in Administration>Financial>Insurance Codes or Insurance Companies).

Patient Eligibility Submit Requests Dialog

When you click the Check Eligibility button () in the Patient component, the Patient Eligibility Submit Requests dialog opens. The window consists of two panes:

The top pane (Eligibility Submit Requests Grid) displays the list of payers that are set for Online Eligibility and for which requests can be sent. By default, all payers are selected, but you can clear the corresponding check boxes if you do not want to send an eligibility request for some of the payers.

The bottom pane (Service Type Code Details Grid) displays the detailed information on the service type codes that will be checked for eligibility. This pane is available only if the Display Service Type Code Details check box in the bottom of this window is selected. You can click the Edit button to edit service type codes and NPI numbers for the selected insurance.

When you click Submit, the requests are submitted to the eligibility vendor.

Checking Payer Eligibility for a Patient

1.	Open the Patient component.

2.	On the toolbar, click and select the appropriate patient from the Select Patient window.

OR
Click and select the patient from the drop-down list. This list includes the most recently accessed patients.

3.	Click in the toolbar.

The Patient Eligibility Submit Requests Dialog opens. You can select the payers and service types that should be verified during eligibility check.

If a patient payer is not set up for Online Eligibility, the following error message appears:
The patients's payer(s) 'Pay Source Insurance Pointers and Codes' are not setup for Online Eligibility verification. Please open the Administration>Configuration>Organizations>Online Eligibility screen and configure the payers applicable to check for Eligibility.

4.	Click Submit.

The application initiates the process to verify the patient's eligibility with the clearinghouse and displays a message indicating the status of the request submission.

>	If the request succeeds, the following message appears: Eligibility request was submitted successfully. Please check patient's Eligibility tab on the Payers screen for response details.

>	If the request fails, a message with error details appears.

Click OK.