Checking Eligibility in firstREV

One very useful feature in firstREV is the ability to run current, real-time eligibility checks and view eligibility responses. As some patients may move between insurance plans frequently, agencies must easily verify eligibility for patients in a timely, secure, and efficient way — whenever they need.

Users can determine if a patient has an active insurance plan (and current benefits for the plan) before initiating service. Checking eligibility for patients prior to service can prevent claim rejections later on. By collecting insurance information (whether private or Medicare) and checking patient eligibility before patients receive services — agencies are able to know exactly what is billable and whether or not you must collect the deductible or copay from the patient. Additionally, Medicare patients often have coverage that changes from month to month, which makes it critical to check eligibility in real-time before service is offered.

With the eligibility features in firstREV, agencies are equipped to effectively conduct a thorough verification process for all patients, as eligibility can be conducted for any payers — not just Medicare.

 

Eligibility checking in firstREV is integrated with the functionality for claims processing. Users simply complete the process of requesting eligibility for a patient after a claim is uploaded. When a user requests eligibility for a patient, firstREV accesses hundreds of commercial, Medicare, and Medicare payers.

firstREV will flag any eligibility issues for the patient and designate them in the editing phase of the claim process — where they can be addressed by the user. This helps agencies avoid claims from being denied and appearing in adjudication.

Medicare eligibility is verified via HETS (HIPAA Eligibility Tracking System) — not the common working file.

 

1.    Using the toolbar, click Patients and then click Request (under the Eligibility menu header).

2.    In the Payer section, specify the Payer for the request using the drop-down menu.

3.    In the Provider section, select the appropriate NPI using the drop-down menu.  

4.    Enter the appropriate Subscriber information:

●     Type the patient’s specific Member ID (e.g. patient HICN, etc.)

●     In the Name section, enter the patient’s First and Last name.

●     Enter the patient’s Date of Birth.

●     Specify the patient’s Gender using the drop-down menu.

5.    Ensure that any fields required by the payer (indicated by red asterisks) are completed.

6.    Click  .

 

Fields that are required (indicated by red asterisks) will vary according to each payer. Additionally, as seen in the sample image above, the specific eligibility request fields that are available will differ between payers (e.g. Group Code, Service Code ). For example, selecting Aetna as the payer will display the Group Number, Eligibility Start, and the Benefits Service Code fields. Most payers allow more than one combination of required query fields.

 

 

Once a user accesses an individual eligibility record, the Eligibility screen will display, as seen in the sample image. Medicare requests include details regarding benefits and coverage. Furthermore, additional payers are listed at the bottom of this screen (if applicable).

In summary, each record includes various details related to the following:

1     Payer

2     Provider

3     Subscriber information

4     Coverage status

5     If coverage is active, inactive, or if another plan is detected

6     The copay or deductible information (if applicable)

7     Messages from the payer (if something needs to be corrected and resubmitted)

 

Similar to functionality in the Patient Folder, each eligibility request record contains two tabs that contain control features. Summarized below is the functionality included with each option in the eligibility control tabs:

1     Transaction

A     Edit & Resubmit — Use this option to resubmit the initial eligibility request associated with the selected response record. After selecting Edit & Resubmit, ensure all the correct information is entered and then click  .

B     Reload — Reload data for the selected response record to ensure that the latest information is displayed on the screen.

C     Mark as Reviewed — Indicate that the eligibility response has been reviewed. When this option is clicked, the software will automatically populate the corresponding information    (i.e. User, Date, Time) in the Provider section of the selected record (as seen in sample image).

D    New Request — Initiate a new eligibility request.

2     Print

A     Response — Generate an eligibility response report as a .pdf file. View the following page for more information on this report.

 

1.    Navigate to Patients | Responses.

2.    Find the desired eligibility request listed in the data grid. If necessary, use the Quick Search menu to narrow down the results displayed.

3.    In the Actions column, click    to resubmit the response record. The Eligibility Request query screen will automatically load. The software will automatically load fields with data that was selected in the initial eligibility request.

4.    In the scenario that an error occurred with the initial request, you will likely need to correct data entered in the appropriate fields. Ensure all data is correct and then click  .

Requests can also be resubmitted from within an individual response record. Hover the mouse cursor over the Transaction tab and then select Edit & Submit. Then simply ensure the correct information is entered and click  .