Eligibility Worklist

 

On the Workflow Dashboard, click a non-zero total in the Eligibility column, in the row for the desired department (the Eligibility Worklist appears in the Task Bar).
Note: A zero total in the Eligibility column indicates that the department has no outstanding eligibility issues.

 

Each entry in the worklist represents a policy whose eligibility status is not conclusively "eligible" (that is, verified) and describes the eligibility issue reported by the payer. You can click a patient name in the list to display that patient's Quickview page.

 

At the top of the Eligibility Worklist, you see the PAYER DOWNTIME section if any payers in the worklist are experiencing problems with their eligibility systems. You can click the name of the payer (in red letters) to display the Eligibility Connectivity Monitoring page, which displays the eligibility connectivity status for payers.

 

Filtering the Eligibility Worklist

You can filter and sort the worklist using one or more of these fields.

• Provider — Select a provider from the list to display eligibility issues for that provider's patients only.
• Issue — Select a specific issue from the list — for example, Ineligible, Demographic, or Member ID — to display only those eligibility issues in the worklist.
• Sort by — Sort the worklist by Issue, Payer, or Appointment Date (the default option).

After you select a filter or sort option, click the Filter button.

Note: If you selected a filter or a different sort order, you can click the Filter button to redisplay the default worklist.

 

1. On the Workflow Dashboard, click a non-zero total in the Eligibility column, in the row for the desired department (the Eligibility Worklist appears in the Task Bar).
   Each entry in the worklist represents a policy whose eligibility status is not conclusively "eligible."
2. Filter and sort the worklist if you choose.
3. Resolve the eligibility issues in the worklist. Depending on the type of issue specified in the worklist, you resolve eligibility issues in different ways.
   Note: As you resolve issues, you can click the Refresh link at the top of the worklist to remove completed items from your list.
   

Downtime eligibility issues

4. For Downtime eligibility issues, you can:
• Click the name of the payer (in red letters) in the PAYER DOWNTIME section at the top of the worklist to display the Eligibility Connectivity Monitoring page, where you can see the eligibility connectivity status for payers.
• Click the Perform eligibility check link in the worklist entry to run the eligibility check again.

Enrollment eligibility issues

5. For Enrollment eligibility issues, you most likely need to call the payer to verify eligibility for the patient. This type of issue indicates that electronic eligibility checking is not available for the provider due to an enrollment or credentialing issue.

Demographic and Member ID eligibility issues

6. For Demographic and Member ID eligibility issues, you need to contact the patient or the payer.
• Demographic eligibility issue: The member's name does not match the payer's file. Please confirm the correct spelling with the patient and the payer.
• Member ID eligibility issue: The member ID does not match the payer's file. Please confirm the member ID with the patient and the payer.
7. After you confirm the patient's name or member ID, click the Update link in the worklist item to display the Update Policy Details page in the Workspace for the selected patient and policy. The policy contact information is summarized at the top of the page.
   Note: In the Eligibility Worklist, the patient whose insurance policy information appears on the Update Policy Details page is indicated by the yellow highlighting on the Update link.
   
8. On the Update Policy Details page, make the corrections to demographic or member ID information.
9. After you update the information, click Update & Check Eligibility.
10. In the Eligibility section of the Update Policy Details page, you can set the eligibility status manually, if needed.
1. Take action on eligibility status — Select the Override payer-returned result option.
   The New status and New reason menus appear.
2. New status — Select the eligibility status.
3. New reason — Select the reason for your update.
4. If you changed the status to Eligible, click Update Policy.
5. If you changed the status to Ineligible, click Deactivate Policy.

Insurance package eligibility issues

11. For Insurance package eligibility issues, you need to contact the patient or the payer. This type of issue indicates that the patient is eligible, but that the selected insurance package may be incorrect.
1. Click the View Details link to display the Payer-Provided Eligibility Details page, where you can view the current policy information.
2. Click the Update link to display the Update Policy Details page in the Workspace for the selected patient and policy. You can edit insurance package information on this page.

Ineligible eligibility issues

12. For Ineligible eligibility issues, you can call the payer to confirm the ineligible status of the patient. This type of issue usually indicates that the patient was found in the payer's files, but was not covered when the eligibility check was run.
• If the payer verifies that the patient is eligible, run the eligibility check again.
• If the payer verifies that the patient is ineligible, you may need to contact the patient to determine whether that patient is covered by another insurance plan.

Other eligibility issues

13. For Other eligibility issues, you most likely need to call the patient. This type of issue usually indicates that the member could not be found in the payer's files. Please verify coverage and all member demographic information.
14. After you verify the patient and insurance information, click the Update link in the worklist item to display the Update Policy Details page in the Workspace for the selected patient and policy.
15. On the Update Policy Details page, make the corrections to demographic or member ID information.
16. After you update the information, click Update & Check Eligibility.

Unavailable eligibility issues

17. For Unavailable eligibility issues, you most likely need to call the payer to verify eligibility for the patient. This type of issue indicates that electronic eligibility checking is not provided for this plan by the payer's eligibility system.