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
request (270) and an eligibility response (271) from a clearing house or payer. This allows the system to determine if the patient's insurance is currently
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.
  
• Make sure that you have purchased Eligibility through your clearinghouse, and know if your practice is
  

invoiced or charged per record check, or if your package is unlimited. You do not want your practice to incur

unexpected charges.

• Obtain User Name and Password from your clearinghouse to check eligibility. The user name and password pair
  

from your clearinghouse will work for both of their SOAP (instant check) or SFTP (batch) Portals. The username and password given

to you by the clearing house should work for all of the Portal(Bridge) interfaces that we support to that clearing house.

For example, the username/password pair from the clearinghouse will work for both their SOAP (instant) and SFTP (batch) Portals.

A customer should at the minimum add both Portals for the system to work at peak efficiency.

• If your clearinghouse does not offer instant eligibility or direct file transfers from and to your Practice Management System,
  

you will still have the ability to manually upload and download your files to and from the clearinghouse just as you did prior

this update.

• Your clearinghouse may require a separate Payer ID to check Eligibility. Please check with your clearinghouse and obtain the
  

eligibility payer IDs that you will need to add to your payer setups. If the the Claims and Eligibility Payer IDs are the same,

you do not do anything to your Payer Setup, but turn the option on under Electronic Eligibility Options as illustrated below.

Electronic Eligibility Options are located on page 2/Billing of your Payer Setup.

• DuxWare Support Staff will assist you with set up once the update is deployed to your system, so it is important that you
  

have consulted your clearinghouse to review your options, obtained user names and passwords, etc. to make the process more efficient.

Eligibility Configuration and Set-up

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

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

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

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

DuxWare supports six Portal types at the current time:

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

These six Portals have a "Portal Mode" associated with them:

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

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

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

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

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
fields, an error message will appear as illustrated below:

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

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
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
current time, there are no setups or changes needed in these two areas.

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

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

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

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

The illustration below shows an example of a GatewayEDI setup with three portals:


Select the "Provider Control" and "Location Control" accordions to see the automatically defined "Provider Link"
and Location Links" for further filter options.
ISA and GS segments should not be edited by the practice.

If you click the "Copy Filter From" button the following dialog will appear. This allows you to copy all the filters
from another "Provider Link".






Selecting the third tab "All Filters" will show a list of all of the filters across all of the "Provider Links" associated
with "Eligibility Setup".




Understanding Filter Rules for when you get the response back from the Clearinghouse

The general idea is that a filter will match an eligibility field (EB) in the Eligibility Response (271). Upon this match, an action
will occur and cause a result to be applied to the Eligibility record.

The screen shot below shows a filter opened for editing.



The filter construction block controls which parts of the eligibility message (EB) the filter will match.
So in the example above, the filter will match any eligibility message field (EB) that has the T information
in the field 1. The lines at the bottom show the raw EB code and the parsed version.

The filter Actions block controls what the filter will do when it matches. Listed below are the possible selections.


Display Action:

• Action Show - This is a default action that will show the match record.
  
• Action Hide - This action will hide the record in the Eligibility edit view.
  
• Action Copay Standard - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Copay Surgery - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Copay Lab - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Copay Percentage - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Copay All - This is a special action that will cause Standard, Surgery, Lab, and Percentage filter records to be created.
  
• Action Deductible Standard - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Deductible Surgery - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Deductible Lab - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Deductible Percentage - Attempt to extract a dollar amount for the matched record and load it into eligibility record and policy record.
  
• Action Deductible All - This is a special action that will cause Standard, Surgery, Lab, and Percentage filter records to be created.
  

Status Action:

• Not Eligible - This filter will cause the eligibility record to be marked as a Automated No - "Not Eligible" status.
  
• Requires Action - This filter will cause the eligibility record to be marked as a Automated Maybe - "Requires Action" status.
  
• Eligible - This filter will cause the eligibility record to be marked as a Automated Yes - "Eligible" status.
  
• No Action - This filter rule will not effect the eligibility records status.
  

Apply actions when segment is absent?:

• Absence No - This filter has to match a line in the 271 response for result to be used.
  
• Absence Yes - This filter must NOT match a line in the 271 response for result to be used.
  

At this point, your Eligibility Setup is complete, and you are ready to begin sending Eligibility Requests and processing the
Eligibility Responses.