The eligibility request (270) contains information about the sender, receiver and patient. The 270 is currently created in the following manner:
Automatic: The Eligibility request is automatically created for new referrals.
- For Home Health referrals it is created at the same time the Verify Medicare Eligibility workflow is created.
- For Hospice referrals it is created at the same time the Verify Medicare Hospice Eligibility is created.
On-Demand: The Eligibility request is created when a user Right Clicks on an episode from the Clinical Input screen> Selects Payor>Selects Send Eligibility Request (270). This option is only available on episodes when the payor associated with the episode has Allow Electronic Eligibility set to Y.
The user can view from workflow by clicking the View Electronic Eligibility Response (271) button or from the patient’s episode (Payor>Select View Eligibility Response 271). This will open the Episode Eligibility Request History screen.
History: This section will show all history for this patient (same patient id) even if the information is from a different episode. The screen will default to the current request.
Request (270): This section will send the request in to be auto checked. It will how data related to the submitted eligibility request for the row highlighted in the History section.
View Request button (on the history screen) will allow the user to view the actual 270 that was submitted for the row that is highlighted in the History section.
Response (271): This section will show information and identified alerts returned in the 271 for the row that is highlighted in the History section.
View Response button (on the history screen) will allow the user to view the 271 in a user-friendly manner for the row that is highlighted in the History section. The first page of the report gives a summary of key information.
View 271 (also on the history screen): Allows the user to view the actual 271 returned for the row that is highlighted in the History section.
HCHB is still reviewing issues that prevent an eligibility request to be sent to CMS or prevent an eligibility response to be returned. As we evaluate the issues, we will make the necessary changes and give users a message that will direct them on what additional action may be required to resolve the error.
Currently an ‘Error in 271’ message may be returned when an eligibility request is created but no response is returned. If this error occurred for a new referral, the Verify Medicare Eligibility workflow will stay open. When the user clicks the View Electronic Eligibility Response (271) button they will see a message in the Response (271) section asking them to try to submit the request again.
If this error occurs, the user has two options. The first option is for the user tomanually verify the patient's eligibilityand the second option is for the user to create an "On Demand Request". Regardless of which option is chosen, someone will still have to manually complete the SOC/Recert workflow in order get the next task to show up on the actions screen. DO NOT right-click to end the SOC workflow.
If the user still experiences problems, please contact support so the error can be researched further.
Below are the current alerts that will initiate the Eligibility Alert workflow:
Client not eligible: Will be returned when the 271 indicates that Medicare A or Medicare B is Inactive.
Medicare Replacement: Will be returned when the 271 indicates that the client has another payor responsible for services. This alert will be returned for policies that may not be the primary payor and the user should refer to the agency policy and procedure for the appropriate action. (Example is “No Fault”)
Medicare Secondary: Will be returned when the 271 indicates that Medicare is secondary. The primary insurance carrier information will also be returned and the agency should review the effective date and take appropriate action.
On service with another Home Health/Hospice: Will be returned when the 271 indicates that the patient has had a previous/current home health and/or hospice episode with another agency. This alert is returned if the NPI number returned for the other agency is different than the agency that sent the request.
Client Demographics: Will be returned when the 271 indicates that information submitted in the 270 is different than what is returned in the 271.