Insurance Eligibility

Summary

This enhancement to Insurance Eligibility adds the ability to display excluded line items from the Insurance Eligibility Details, to assist in identifying relevant details, such as the matching rule and the excluded line items.

Background

Previously, if an eligibility return was affected by a special conditions rule, it was impossible to determine which rule was applied and which items were excluded from the return.

When eligibility is run, RIS chooses the highest co-pay and co-insurance and the lowest deductible from the insurance return. Due to Eligibility Special condition rules (such as the co_insurance only applying to inpatient or another more complex rule) some of the line items in the return are excluded.

For this reason, the Insurance Eligibility Details dialog includes a Show ALL option. However, this doesn't show why each missing item was removed.

Feature Description

With this change, a new Show Excluded Line Items grid has been added to the Insurance Eligibility Details dialog:

Show Excluded Line Items option in the Eligibility Details dialog. 

This new dialog will show:

·         Rule matching string that caused the exclusion

·         The eligibility_special_condition_key that caused the exclusion

·         Description from eligibility_special_condition (which we can use to give a user friendly name to the exclusion).

·         Text that was excluded

excluded information displayed in the new show excluded line items grid

Configuration Instructions

No System Administrator actions are necessary to enable this feature.

Database

Changes to Database

A new c_eligibility_response_excluded table has been added to the database to store these new values.

Summary

This enhancement to Insurance Eligibility facilitates reporting and analytics of eligibility information by storing 271 Results to the RIS database.

There are no customer-facing changes.

Feature Description

With this change, RIS will begin storing 271 Results to dedicated RIS database tables. This allows the analytics team to more easily query specific details contained within the 271 and help with targeting verbiage and other details within the 271 when creating rules.

Service Team Upgrade Instructions

No Service Team actions are necessary to deploy this feature.

Database

Changes to Database Schema

The following tables have been added for querying and reporting purposes:

c_eligibility_json_provider

c_eligibility_json_additional_insurance

c_eligibility_json_financial

These will be used in conjunction with the existing c_eligibility_response table, which is currently used to store select insurance details.

Configuration Instructions

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

RIS Client

Changes to SystemConfig Lookup Table

·         Optionally enable Enable271AnalyticsDataStorage for your installation.

o    The default value leaves existing system behavior unchanged.

The following related settings were added or updated: