Insurance Management

Summary

This enhancement to Insurance Management expands the override functionality in the AI determination process.

Feature Description

Previously, the "AI is wrong" workflow lacked detailed information when the override function on the AI determination was used.

With this change, a new Carrier Switch Details link will display under the Manage Policies grid when a carrier switch has occurred.

The link will provide a history of every carrier switch executed on that visit. The information provided will include the time/date, user and details relating to the switch that was performed.

Additionally, the Carrier Switch Details dialog will provide users with the option to include pertinent notes relating to the visit.

Users with permissions now have the ability to disable carrier switching by utilizing the Disable Carrier Switching (RIS is wrong) toggle in the Carrier Switching Details dialog.

In order to disable carrier switching, a note must be provided to proceed. If the user fails to provide a note, they will be prompted with a warning message and will be prevented from closing the dialog until the note is added.

However, if the toggle is selected and a note is provided the link will be updated to display as Carrier Switching Disabled in red font.

Configuration Instructions

System Administrators must complete the following actions to enable this feature:

·         Set an active condition for a carrier switch in the EligibilitySpecialConditions table

·         Configure system config, CarrierSwitchingViaEligibilityWarningsEnabled to True

·         Set access to desired user groups via Clinical.CarrierSwitching.OverrideAccess

RIS Client

Changes to AccessString Lookup Table Settings

·         Grant access permissions as necessary.

The following related settings were added or updated:

Summary

This enhancement to Insurance Management introduces the ability to configure Carrier Switching directly in RIS to support customers who wish to utilize carrier switching but do not have access to the AI Gateway.

Background

Previously, Carrier Switching functionality was only available via the use of the AI DLL (as provided by Feature #22300), which was not accessible to all customers.

Feature Description

With this change, Carrier Switching configuration of Matching String and Warning Message values is now performed via the Eligibility Special Conditions table which will allow for carrier switching when eligibility is run:

Configuration Instructions

System Administrators must complete the following actions to enable this feature:

1.       Access ConfigFile Lookup table:

1.1.    Ensure no values are present for AI DLL.

1.2.    Restart RIS if existing values were removed

2.       Set CarrierSwitchingViaEligibilityWarningsEnabled to TRUE.

3.       Configure a rule within the Eligibility Special Conditions lookup table to show a warning

RIS Client

Changes to SystemConfig Lookup Table Settings

The following related settings were added or updated:

Summary

This enhancement to Insurance Management introduces improved carrier warnings and updated functionality for AI insurance selection.

Background

Previously, if additional insurance information was included in the eligibility return, the only way to communicate that a change was required was through an eligibility warning. Once this warning was acknowledged, manual input was still required to implement the change.

For example, there are insurance returns where the results from the payer explain that the patient has additional insurance such as Medicare Part B as the primary payer. Currently the RIS can only advise via warnings in these multi carrier situations as to what the schedule or IVT staff can do to handle the situation. Also, with these warnings RIS does not currently have the ability to include the policy number that should be used for that new primary insurance selection.

Feature Description

With this change, warning messages are now more dynamic and can allow for other parameters to be considered while configuring a rule.

Additionally, if the eligibility response returns with multiple insurance policies the system will auto-populate them into the Manage Policies grid.

Improvements to carrier warnings:

1.       A new syntax in the warning messages to create or enforce a carrier recipe such as:

For example:

2.       The OptionalPolicyNumber in the syntax (i.e., ABC123kjf in the above example) is dynamic, meaning it will come from somewhere in the patient's insurance return. For this, the 'Edit SQL' will have a new filter column. Then in building the warning message that value can be referenced as a parameter such as:

3.       The warning messages will also be made more dynamic by allowing for other parameters such as:

Notes on Switching and Carrier Creation Automation

This functionality is enabled via the CarrierSwitchingViaEligibilityWarningsEnabled RIS system configuration setting introduced by Feature #34305, also included with this release.

System logic when more than one carrier is specified using the format discussed above:

·         If the carrier already exists for the patient with a matching policy number, it will be selected for use.

·         If the carrier/policy didn't exist for the patient a new carrier row will be added for the patient with the policy number with the Relation to Subscriber as self.

If the carrier to switch to in the warnings does not have an OptionalPolicyNumber specified in the warning:

·         Then any of the existing carriers for the patient that match on carrier code can be used (regardless of policy number)

·         If the patient's existing carriers do not contain the carrier_code, then a new carrier will be created with the Policy Number text of "" and the Relation to Subscriber as Self.

Configuration Instructions

No System Administrator actions are necessary to enable this feature; however, optional configuration is available.