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NCPDP Eligibility Verification (E1) Request - PM

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Create an E1 request file to be processed by DayTech. The E1 transaction set is used to check a client's eligibility within the Medicare Part D program.

myAvatar PM > Billing > Electronic Submission > NCPDP Eligibility Verification (E1) Request

  1. In the Clients To Include field, select the clients to check for eligibility.
    • All clients 65+ years old, and those younger but with Medicare Coverage
      • These requests are neither guarantor nor episode specific.
      • Clients are included if they meet the following conditions:
        • 65 years old or older, and is an active client - we do no look at guarantor coverage in order to consider these clients. As long as they are an active client 65 years or older as of the Effective Date, then the client will be picked up.
        • Is an active client as of the Effective Date and has a guarantor assigned to their Financial Eligibility that is classified as a Medicare Guarantor. This is being identified as any guarantor with the Financial Class dictionary's extended attribute UB-92 Source of Payment (Record 30-4) equal to MEDICARE.
        • Is active in an inpatient program as of the Effective Date (does not pick up outpatient or pre-admit programs).
    • All clients flagged for a request via financial eligibility
      • These requests are guarantor specific and, in the case of standard Financial Eligibility, episode specific. 
      • The client must be Active as of the Effective Date in that episode (episodic) or any episode (non-episodic). 
      • The requests are made within the Financial Eligibility forms (Financial Eligibility, Cross Episode Financial Eligibility and Family Financial Eligibility) using the NCPDP Eligibility Verification (E1) Request Status prompt.
      • The client must be assigned a Medicare Part D Guarantor. Only guarantors which have the extended dictionary System Financial Class set to NCPDP - Medicare Part D are considered Medicare Part D.
    • Individual client
      • These requests are neither guarantor, age, nor episode specific.
      • The client needs to be active as of the Effective Date.
      • The Client ID field is enabled and required by this selection.
  2. Click View Clients Flagged For A Requested to launch a report on the clients that have been flagged for an Eligibility Request through a Financial Eligibility form.
    Note: When a guarantor is selected, only the requests for that guarantor will be listed.
  3. In the Client ID field, select the client to check for eligibility. This field is enabled when Individual Client is selected in the Clients To Include field.
  4. In the Guarantor field, select the guarantor to eligibility against. Only those guarantors defined as an NCPDP Guarantor display.
  5. In the Options field:
    • Select Compile File to create a request for the Effective Date specified. The Effective Date is representative of the date of service for which eligibility is being checked. Only one file can exist in a state of compile at any one time for a specific set of parameters (Clients To Include and, if applicable, Client ID, or Guarantor).
    • Select Run Report to launch a report of the client included in the compile as well as the response status. Statuses are:
      • Request Not Submitted - The request file has been compiled but not yet created on the server.
      • Response Unavailable - The request file has been created on the server but the response file has not yet been processed.
      • A specific NCPDP status as reported back to myAvatar as a result of the request file having been processed.
    • Select Delete File to remove a compiled file before it is created on the server.
    • Select Create File On Server to move the compiled file onto the server for submission to DayTech.
      Note: This will create a temporary NCPDP submission file (with .tmp extension) that is then changed once it is complete (to a .txt extension) so that CE2000 cannot import a submission file while myAvatar is still writing to it.
  6. In the File Description field, enter a description to be associated with the file. This field is only enabled when compiling a file.
  7. In the Effective Date field, enter the effective date for which eligibility should be checked. The system will warn you if the effective date is more than 90 days prior to the current date. This field is required when compiling a file.
  8. The Effective Date of Most Recent Request field displays the date of last request for the selected parameters (Clients To Include and, if applicable, Client ID, or Guarantor).
  9. In the Select File field, select the file to report, dump, create, or delete. This will show all requested files created fro the selected parameters (Clients To Include and, if applicable, Client ID, and Guarantor). This is required when creating, reporting on, or deleting a file. The files will be ordered from most recent to oldest with the exception being any file that has not yet been posted, which will be shown first regardless of date.
  10. Click Process File.