Insurance Eligibility

Summary

This enhancement to Insurance Eligibility introduces the option to transmit place of service and tax values in accordance with the 270/271 specification.

Previously, these values were not sent, resulting in failures from some payor returns.

With this change, a new Include Place Of Service Tax And Address column has been added to the EligibilePayers and AvailityPayers RIS Lookup Table Editors which, when Y will transmit the following site-level information (or practice level if address information info isn't available at the site level):

·         provider_street_line_1

·         provider_street_line_2

·         provider_city

·         provider_state

·         provider_zip

·         service_provider_tax_id

 Configuration Instructions

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

RIS Client

Changes to other RIS Access Tables

• Update the Include Place Of Service Tax And Address column in the EligibilePayers and AvailityPayers RIS Lookup Table Editors for your organization.

Summary

This enhancement to Insurance Eligibility introduces a Send Dependent Flag, column in the AvailityPayers lookup which when set to N will always submit as though the patient is the policy holder.

Previously, HL4 dependent loop submissions to Availity for Medicare members on our Real Time Eligibility Requests resulted in 999 errors from Medicare, causing rejections on Availity’s end.

Configuration Instructions

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

RIS Client

Changes to other RIS Access Tables

• Update the Send Dependent Flag, column in the AvailityPayers RIS Lookup Table for the payers at your organization.

Summary

This enhancement to Insurance Eligibility creates a warning based on the presence of a secondary insurance policy.

Currently, if a warning is created on the primary insurance, the user would have to override it after adding the secondary insurance. This is time consuming and confusing to the user.

With this change, if the 271 data from the primary insurance policy contains an additional insurance policy or the word “dual,” a warning will appear on the primary insurance. To resolve the warning, the user must enter the appropriate secondary insurance policy. The warning would then be resolved and turn to a green check once the secondary policy is added.

In the following example, RIS issues a warning when the user has a primary insurance, but the secondary isn't carrier code 1116 or xyz and the primary insurance has DUAL in the plan name or additional insurance policies: