View source for Eligibility, 270, and 271 Management

==DuxWare Eligibility User Guide==

====Introduction====

DuxWare Eligibility is designed to enable the practice to generate an electronic record for the policy of a particular patient that tracks an eligibility<br>
request (270) and an eligibility response (271) from a clearinghouse or payer. This allows the system to determine if the patient's insurance is currently<br>
active and providing benefits on claims filed to them.

'''Before you begin:'''

* Setup for the DuxWare Eligibility Manager requires a Level 5 Management User to add or edit in this area.<br>
* Make sure that you have purchased Eligibility through your clearinghouse, and know if your practice is<br>
:invoiced or charged per record check, or if your package is unlimited. You do not want your practice to incur<br>
:unexpected charges.<br>
* Obtain User Name and Password from your clearinghouse to check eligibility. The user name and password pair<br>
:from your clearinghouse will work for both of their SOAP (instant check) or SFTP (batch) Portals. The username and password given<br>
:to you by the clearinghouse should work for all of the Portal(Bridge) interfaces that we support to that clearinghouse.<br>
:For example, the username/password pair from the clearinghouse will work for both their SOAP (instant) and SFTP (batch) Portals.<br>
:A customer should at the minimum add both Portals for the system to work at peak efficiency. <br>
* If your clearinghouse does not offer instant eligibility or direct file transfers from and to your Practice Management System, <br>
:you will still have the ability to manually upload and download your files to and from the clearinghouse just as you did prior <br>
:this update.
* Your clearinghouse may require a separate Payer ID to check Eligibility. Please check with your clearinghouse and obtain the<br>
:eligibility payer IDs that you will need to add to your payer setups.  If the the Claims and Eligibility Payer IDs are the same,<br>
:you do not do anything to your Payer Setup, but turn the option on under Electronic Eligibility Options as illustrated below.<br>
:Electronic Eligibility Options are located on page 2/Billing of your Payer Setup.<br>
<br>
[[File:PayerSetupEligopt.png]]
<br>
* DuxWare Support Staff will assist you with set up once the update is deployed to your system, so it is important that you<br>
:have consulted your clearinghouse to review your options, obtained user names and passwords, etc. to make the process more efficient.<br>


<br>
<br>
<br>

===Eligibility Configuration and Set-up===

Eligibility Manager Configuration and Setup can be accessed under the Appointments Tab as illustrated below:<br>

[[File:EligMgrAccess.png]]

Once you select the Eligibility Manager, the first thing to do is to setup a portal(bridge) to use for getting eligibility data.<br>
You will need a username/password from your clearinghouse. The username and password given to you by the clearinghouse should work <br>
for all of the Portal(Bridge) interfaces that we support to that clearinghouse. For example, the username/password pair from <br>
gatewayEDI will work for both their SOAP (instant/real-time) and SFTP (batch)Portals. A customer should at the minimum add both Portals<br>
for the system to work at peak efficiency. <br>

[[File:EligAddSetup.png]]

Select the "Add" button at the top to call up the "Eligibility Setup" creation dialog:

[[File:EligAddEdit.png]]

At this point, you should select "Add New portal" button located at the bottom of the portal table as illustrated above.<br>

[[File:Select_PortalTemplate.png]]

'''DuxWare supports the following Portal types at the current time:'''<br>

'''Manual Portal''' - Manual - This Portal/bridge does not send the eligibility request(270) to any clearinghouse. It is only <br>
used for customers that will manually upload/send the eligibility request(270) to the clearinghouse. It also allows for filters<br>
to be created against it so the full functionality of eligibility is present for manual systems.<br>
'''GATEWAYEDI SFTP''' - Automatic - This is the SFTP portal. This is mainly used for bulk processing. The turn around on a request <br>
is about 5 minutes.<br>
'''GATEWAYEDI SOAP''' - Real Time - This is the SOAP portal. This is mainly used for single request needing an immediate answer.<br>
The turn around on a request is about 1 minute.<br>
'''MDOL SFTP''' - Automatic - This is the SFTP portal. This is mainly used for bulk processing. The turn around on a request is <br>
about 2 to 12 hours.<br>
'''NAVICURE SFTP''' - Automatic - This is the SFTP portal. This is mainly used for bulk processing. The turn around on a request is <br>
about 2 minutes.<br>
'''NAVICURE SOAP''' - Real Time - This is the SOAP portal. This is mainly used for single request needing an immediate answer, The turn<br>
around on a request is about 1 minute.<br>

'''These Portals have a "Portal Mode" associated with them:'''<br>

'''Manual''' - This portal will only create the 270 locally or process the 271 from a local source. If there are no Automatic or Real<br>
Time portals, then all eligibility request will fail over to this portal.<br>

'''Automatic''' - This portal mode is used primary for bulk processing (Checking more than 1 eligibility at a time). If there is no <br>
Real Time portal then Real Time request (Eligibility Quick Check) will fail over to this Portal.<br>

'''Real Time''' - This portal mode is used primary for single processing (Checking 1 eligibility at a time). If there is no Automatic<br>
portal then a Bulk request will fail over to this Portal.<br>

For this example, you select the "GATEWAY SFTP Eligibility" Portal to add to the system. The "Portal Add" dialog will now appear as this:<br>

[[File:Portaltemplate.png]]

The only fields the end user needs to fill in are "Username" and "Password". If you try to add this portal without filling in those two <br>
fields, an error message will appear as illustrated below:<br>

[[File:ErrorUserNm.png]]

You can close the dialog box and enter the Username and Password and click the "Add" button.<br>

The screen will go to the "Eligibility Setup" tab of the "Eligibility Portal Setup" dialog. It will fill in the Portal field with the Portal<br>
that you just created. It also fills in any unique values for the portal into the ISA and GS segments located in the accordion tabs. At this<br>
current time, there are no setups or changes needed in these two areas.<br>

[[File:EligSetupTab.png]]


If you select "Add" at this point in the process, you will receive the following error.<br>

[[File:EligSetupNmErr.png]]

Name your setup, and select the save button and the "Eligibility Setup" will be saved. This will cause a the following actions to occur:<br>

* The Provider Link and Eligibility Response Filter tab will become active.<br>
* There will be a generic Provider Link record created.<br>
* The generic Provider Link record will get a default set of filters.<br>
* A bridge representing the portal will be added.<br>

'''NOTE:''' You will optimally add three portals to your Eligibility Setup: Manual, Automatic (SFTP)and Real-time (SOAP).<br>
Currently, MD On-line (MDOL) only supports Manual and Automatic.<br>
For example, you will add GatewayEDI Eligibility Setup named, "GatewayEDI", you would then need to <br>
"Add New Portal": Manual, then again for Automatice (SFTP), and then again for Real-time (SOAP).<br>

[[File:EligibilitySetup1.png]]
<br>
<br>
The illustration below shows an example of a GatewayEDI setup with three portals:<br>
<br>
[[File:Gatewayportals.png]]
<br>
Select the "Provider Control" and "Location Control" accordions to see the automatically defined "Provider Link"<br>
and Location Links" for further filter options.<br>
ISA and GS segments should not be edited by the practice.<br>


[[File:ELigFilterGroups.png]]
<br>
<br>
<br>
[[File:ELigFilterGroups.png]]
<br>
If you click the "Copy Filter From" button the following dialog will appear. This allows you to copy all the filters<br>
from another "Provider Link".<br>
<br>
[[File:EligCopyFilterFrom.png]]
<br>
<br>
Select the edit icon to the left of the filter to review/edit the filter.  You will land at the Filter Editing Screen as<br>
illustrated below:<br>
<br>
<br>
<br>
[[File:EditFilterSet.png]]
<br>
<br>
<br>
[[File:Eligfilteredit2png.png]]
<br>
<br>
<br>
Selecting the third tab "All Filters" will show a list of all of the filters across all of the "Provider Links" associated<br>
with "Eligibility Setup".<br>
<br>
<br>
[[File:EligAllFilters1.png]]
<br>
<br>
'''Understanding Filter Rules for when you get the response back from the Clearinghouse'''<br>
<br>
The general idea is that a filter will match an eligibility field (EB) in the Eligibility Response (271). Upon this match, an action<br>
will occur and cause a result to be applied to the Eligibility record.<br>
<br>
The screen shot below shows a filter opened for editing.
<br>
[[File:Eligfilterexample1.png]]
<br>
<br>
<br>
The filter construction block controls which parts of the eligibility message (EB) the filter will match. <br>
So in the example above, the filter will match any eligibility message field (EB) that has the T information<br>
in the field 1. The lines at the bottom show the raw EB code and the parsed version.<br>
<br>
The filter Actions block controls what the filter will do when it matches. Listed below are the possible selections.<br>
<br>
<br>
'''Display Action:'''<br>
<br>
* Action Show - This is a default action that will show the match record.<br>
* Action Hide - This action will hide the record in the Eligibility edit view.<br>
* Action Copay Standard - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Copay Surgery - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Copay Lab - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Copay Percentage - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Copay All - This is a special action that will cause Standard, Surgery, Lab, and Percentage filter records to be created.<br>
* Action Deductible Standard - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Deductible Surgery - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Deductible Lab - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Deductible Percentage - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.<br>
* Action Deductible All - This is a special action that will cause Standard, Surgery, Lab, and Percentage filter records to be created.<br>
<br>
<br>
'''Status Action:'''<br>
<br>
* Not Eligible - This filter will cause the eligibility record to be marked as a Automated No - "Not Eligible" status.<br>
* Requires Action - This filter will cause the eligibility record to be marked as a Automated Maybe - "Requires Action" status.<br>
* Eligible - This filter will cause the eligibility record to be marked as a Automated Yes - "Eligible" status.<br>
* No Action - This filter rule will not effect the eligibility records status.<br>
<br>
<br>
'''Apply actions when segment is absent?:'''<br>
<br>
* Absence No - This filter has to match a line in the 271 response for result to be used.<br>
* Absence Yes - This filter must NOT match a line in the 271 response for result to be used.<br>
<br>
<br>
At this point, your Eligibility Setup is complete, and you are ready to begin sending Eligibility Requests and processing the <br>
Eligibility Responses.<br>
<br>
<br>
<br>
====Eligibility Quick Check via Patient's Account====

In order to use Eligibility Quick Check, your clearinghouse must provide a Real-time access (SOAP) interface. <br>
Your Eligibility Manager Configuration and Set-up must be complete.  Eligibility ID should be input in the<br>
Payer Setup if different from the Claims Payer ID.<br>
<br>
There are three areas in DuxWare to access the Eligibility Quick Check interface:
<br>
* Insurance Policy Add/Edit (located on the first screen of the patient information screen).<br>
* Appointment Schedule <br>
* Eligibility by Appointment (located under the "Appointments" tab)<br>
<br>
'''Insurance Policy Add/Edit:'''<br>
Retrieve the patient's account and select the insurance payer that you wish to Quick Check. Scroll down to the <br>
bottom of the page and select [Eligibility Quick Check].<br>
<br>
<br>
[[File:Eligquickpayer1.png]]
<br>
<br>
[[File:SelectEligQC.png]]
<br>
<br>
Below is an example and Insurance Policy Add/Edit in the Patient's account. In this example, the user <br>
is viewing a policy and selected the "Eligibility Quick Check" button. The Quick Check dialog has auto-selected <br>
the patient's default provider, default location, and the policy that is being viewed. In this case, it still allows<br>
the user to select a different Provider or Location because they are on the policy view and could be checking to see if<br>
a different Provider or Location will work better with the current Policy.<br>
<br>
<br>
[[File:EligSoapQC.png]]
<br>
<br>
Below is the response that was received from the clearinghouse indicating that the patient was not eligible.<br>
At this point, the user will need to verify that patient information was input correctly before contacting the <br>
the patient for updated insurance information. Be sure to review the messages provided to guide you as to why the<br>
response was returned as ineligible. You can view messages by clicking the small icon next to the message to expand<br>
for viewing. You can also view the raw response message by selecting the tab labeled "Eligibility 271 Message.<br>
If you determine that the response should have been valid, modified the rule, etc. you can select [Save], or you can<br>
[Save as Invalid] if you determine that the payer was correct with sending back that the patient was not eligible.<br>
<br>
<br>
[[File:EligQCFilterRsp.png]]
<br>
<br>
We have decided that the payer was correct with their invalid response, and select [Save]. Below is how it will display on<br>
the insurance payer on the Patient Information Screen.<br>
<br>
<br>
[[File:EligRespSave.png]]
<br>
<br>
'''NOTE: '''Unfortunately, we can not show live responses for our users to see what the Eligibility system is really capable of, <br>
but we are confident that you will catch on quickly.  As always, we encourage you to call our support line if you need<br>
assistance or have questions at 1(800)248-4298. <br>
<br>
<br>
<br>

====Appointment Schedule Quick Check====
<br>
<br>
In order to use Eligibility Quick Check, your clearinghouse must provide a Real-time access (SOAP) interface.<br>
Your Eligibility Manager Configuration and Set-up must be complete. Eligibility ID should be input in the<br>
Payer Setup if different from the Claims Payer ID.<br>
<br>
<br>
The Front Desk now has the ability to perform an Eligibility Quick Check from the Appointment Scheduler.<br> 
The patient's information should be complete with the policy information fully added to the patient's account.<br>
<br>
As illustrated below on the "Appointment Scheduler" screen, the user will mouse right-click on the appointment.<br>
and select "Eligibility Quick Check" from the right click popup menu.<br>
<br>
<br>
[[File:EligQCSelectappt.png]]
<br>
<br>
[[File:EligQCpopupappt.png]]
<br>
<br>
Which will cause the Eligibility Quick Check dialog to appear. The Quick Check dialog has already selected the Provider<br>
and Location based off the appointment information. The Policy field is still allowed to be changed from the Primary in the<br>
case the staff understands this appointment will be covered by a secondary Policy.<br>
<br>
<br>
[[File:EligSoapQC.png]]
<br>
<br>

====Eligibility by Appointment Report Quick Check====
<br>
<br>
[[File:EligbyapptaccessQC.png]]
<br>
<br>
<br>
To perform a Quick Check from the Eligibility by Appointment Report, select the second icon on the row<br>
to perform an Eligibility Quick Check as illustrated below.<br>
<br>
<br>
[[File:EligbyapptreportQC.png]]
<br>
<br>
Once the Quick Check Icon has been selected, the Quick Check Dialog will appear.  The Provider, Locations and<br>
Policy are automatically locked. In this report, the appointments are sorted by their primary policies as <br>
opposed to the Appointment Scheduler view.<br>
<br>
<br>
[[File:EligSoapQC.png]]
<br>
<br>
<br>
====Eligibility via Bulk Checking====
<br>
<br>
There are two locations in DuxWare available to perform Eligibility Bulk Checking:<br>
* Eligibility by Appointment Report<br>
* Automatically check eligibility via the Eligibility Portal Setting.<br>
<br>
<br>
'''Bulk Checking via the Eligibility by Appointment Report'''
<br>
To access the Eligibility by Appointment Report, see the illustration below:<br>
<br>
[[File:EligbyapptaccessQC.png]]
<br>
<br>
On the top of the Eligibility by Appointment Report, there is a "Check Eligibility"<br>
button that will cause the bulk checking dialog to appear as illustrated below.<br>
<br>
<br>
[[File:CheckEligibilities.png]]
<br>
<br>
After selecting the "Check Eligibilities" button, the following dialog box will appear.<br>
It will display the number of eligibility records that will be sent and how they will be sent<br>
through to the clearinghouse. By default, the Automatic Portal is selected which will allow the<br>
system to choose a portal automatically based off of the chosen criteria.  The criteria is an<br>
Automatic Portal, then a Real-time Portal, then a manual portal.  The appointments it will choose<br>
to select is based on the following criteria:<br>
<br>
* The appointment appears in the table of "Eligibility by Appointment Report".<br>
* The appointment is within 30 days of now (future or past).<br>
* The patient has a policy.<br>
* The last valid Eligibility for the appointment is not Yes, Maybe or No.<br>
<br>
<br>
The "Start Check" will cause the system to send the relevant data to the clearinghouse for processing.<br>

<br>
<br>
[[File:BatchEligChkDialog.png]]
<br>
<br>
This dialog shows you how many eligibility request you are going to send and how they will be sent. By default<br>
the Automatic Portal is selected which will allow the system to choose a portal automatically based off of chosen<br>
criteria. The criteria is a Automatic Portal, then a real time portal, then a manual portal. The appointments it will<br>
chose to select is based off the following criteria:<br>
<br>
* The appointment appears in the table of "Eligibility by Appointment Report".
* The appointment is within 30 days of now (future or past).
* The patient has a policy.
* The last valid Eligibility for the appointment is not Yes, Maybe or No.
<br>
The "Start Check" will cause the system to send the relevant data to the clearinghouse for processing. As times for <br>
large data transactions will vary the "Eligibility by Appointment Report" will not automatically update. In general the<br>
fastest turn around time is 3 minutes the slowest is 18 hours.<br>
<br>
The Eligibility Portal Setting is controlled in the portal settings as illustrated below.<br>
<br>
[[File:EligportalSFTPsetting.png]]
<br>
<br>
The allowed values for "Activate Tomorrow Bulk Eligibility Checking" are No, Yes, and a number. The number represents how<br>
far away tomorrow is in days. This report runs at early in the morning so it will check that days appointments which is <br>
represented by the number 0. If you want the system to check the day after appointments use the number 1. The day after<br>
setting is required for the MDOL sftp interface due to the large latency in getting results.<br>
<br>
The allowed values for the "Status for tomorrow to Check" may be one of the words in the list below (case matters). It is <br>
highly recommended the "Unknown" word be used.<br>
<br>
* Unknown - The last valid Eligibility for the appointment is not Yes, Maybe or No.<br>
* Error - The last valid Eligibility for the appointment is None, Error, Expired.<br>
* Not Yes - The last valid Eligibility for the appointment is not Yes.<br>
* No - The last valid Eligibility for the appointment is No. <br>
* Yes - The last valid Eligibility for the appointment is Yes.<br>
* Maybe - The last valid Eligibility for the appointment is Maybe.<br>
* All - The last valid Eligibility for the appointment is not checked at all.<br>
<br>
<br>
====Eligibility Request (270) via Manual Download====
<br>
<br>
If you are reviewing this area of the user guide, it is likely that your clearinghouse does not support eligibility real-time or SFTP batch<br>
processing. The manual process is identical to our previous Eligibility Module with the exception that it is now in the 5010 format.<br>
<br>
To download an eligibility request file (270), you will need to create a Manual Portal in the Eligibility Manager. <br>
From the Appointments tab, select Eligibility Manager, then Eligibility.<br>
<br>
<br>
[[File:EligMgrAccess.png]]
<br>
<br>
[[File:EligAddSetup.png]]
<br>
<br>
[[File:EligAddEdit.png]]
<br>
<br>
[[File:Select PortalTemplate.png]]
<br>
<br>
Once you have added the Manual Portal, go to Eligibility by Appointment, make your selections, then check Eligibility.<br>
<br>
<br>
[[File:EligbyapptaccessQC.png]]
<br>
<br>
[[File:EligApptDownload.png]]
<br>
<br>
[[File:EligGenerate270.png]]
<br>
<br>
Once "Generate 270" has been selected, you will see a dialog box as illustrated below.  Make sure to select<br>
'''Save File'''.  You will need to upload this file to your clearinghouse. Depending on your Browser download<br>
settings, the file will either be saved to your Desktop and/or your Downloads.<br>
<br>
<br>
[[File:EligSave270.png]]
<br>
<br>
====Eligibility Response (271) Manual Upload and Processing====

In the event that your clearinghouse does not support real-time or batch portals, manual upload for eligibility<br>
responses (271) is still available.  The process works the same as DuxWare's system prior to this update with the exception that this<br> 
update is in the 5010 format and has added features.<br>
<br>
<br>
Before you begin the Manual Upload process,you must first download the Eligibility Response file (271) from your clearinghouse.<br>
The file should look similar to the illustration below:<br>
<br>
[[File:Elig271file.png]]
<br>
<br>
To access the Eligibility Upload, Appointments tab>Eligibility>Eligibility File Upload:<br>
<br>
<br>
[[File:EligFileUploadAccess.png]]
<br>
<br>
You will need to select the "Manual Bridge" from the drop down menu for the Portal, browse,pick your file and select<br>
"Process File" as illustrated below:<br>
<br>
<br>
[[File:EligUploadProcess.png]]
<br>
<br>
To view the processed Eligibility Response, go to the Appointments tab>Eligibility>Eligibility Manager.<br>
Select the fourth tab "Recent Responses(271). Then select the "+" sign to the left of the eligibility response<br>
that you just uploaded.  "+" will expand; edit will allow the user to manipulate responses for your practice.<br>
See section for Understanding the Rules in the Eligibility Configuration and Set-up section of the User Guide.<br>
<br>
<br>
[[File:EligView271processed.png]]
<br>
<br>

===Eligibility Response Examples from the Patient's Account===
<br>
<br>
When the clearinghouse has returned the data, Duxware will automatically update the Eligibility records. See Illustrations<br>
below:<br>
<br>
[[File:EligPtInfoPayer.png]]
<br>
<br>
If you mouse-hover over each policy at the bottom to the Patient Information screen, more detail is provided as illustrated below.<br>
<br>
[[File:EligMouseHover.png]]
<br>
<br>
To view the actual eligibility responses, select the payer from the Patient Information screen, then scroll down to view the<br>
eligibility responses. <br>
<br>
[[File:EligPayerResponse.png]]
<br>
<br>
To edit view response messages or edit filters, select the "+" icon to view and the edit icon to edit the response rule.<br>
<br>
<br>
To view and drill down to details of the eligibility response, select the plus icon to expand as illustrated below:<br>
<br>
[[File:EligExpand.png]]
<br>
<br>
You will see four tabs:
* Results
* Notes
* Eligibility 270 (request) message
* Eligibility 271 (response message
<br>
<br>
[[File:EligResults.png]]
<br>
<br>
To view and edit the eligibility response, select the edit icon.  You will be able to edit the response rules from this area.<br>
<br>
<br>
[[File:EligEditIcon.png]]
<br>
<br>
[[File:Eligeditdrilldown.png]]
<br>
<br>
If you decide to edit the filter, be sure to save your change at the bottom.<br>
<br>
<br>
[[File:EligdrilldownFilteredit.png]]
<br>
<br>