Eligibility Workflow Refactoring

Fusion v6.0 is capable of performing eligibility checks on patients in either a batch or real-time manner using 270 and 271 transactions for most major payers. This provides validated payer information on most patients, reducing the number of problems prior to sending the claim to the payer. The system thus reduces the most common types of denial received in the laboratory billing process.

Fusion creates 270 eligibility transactions, sends them to the appropriate payer and then holds the claim until the 271 response is received back from the payer. The 270 generates as soon as the charge has had a payer identified for it.

The 271 response is evaluated and a pass or fail result is processed. If it passes, the claim is released assuming no other edits are present. If it fails, the claim is put in a worklist for user action. Additional information on 271 responses may need to be evaluated based on the response. The claim is automatically fixed, ignored, or based on the specific response, put on the worklist for user intervention.

 

Eligibility Checking

Fusion can check eligibility for the top common payers across the country including:

• Medicare
• Medicaid for the appropriate state.
• Blue Cross/Blue Shield for the appropriate state.
• Cigna
• Tricare
• Aetna
• United Heatlhcare
• Humana
• UMR
• Wellcare
• Other payers specific to your needs.

 

Response Information

The primary pieces of information that can be gathered from a 271 include:

• Current active insurance coverage for the patient.
• Correct patient name for spelling; first name, middle name or initial and last name.
• Correct patient demographics; address, gender, SSN and date of birth.
• Correct subscriber ID.
• Current payer and relationship code.
• Current Part A and Part B Medicare status.
• Current Nursing home status.
• Current Hospice status.
• Current ESRD status.

 

Technical Details

The following scrub IDs have been modified to write to the ClaimCheck.AutoUpdate table instead of to the HL7 message table:

• Scrub ID 373: Relationship Updated
• Scrub ID 378: Medicare Indicated as Primary
• Scrub ID 379: On Medicare Hospice Status
• Scrub ID 390: Successful ClaimCheck Search
• Scrub ID 395: ClaimCheck Message AutoChargeTo

In addition, scrub ID 366, AutoUpdate Change from ClaimCheck, was modified to use the updates posted to the ClaimCheck.AutoUpdate table to modify the appropriate tables in Fusion.

 

Included features are:

• The IT admin or Fusion guru can enter an action for any of the 271 responses listed above; autofix, place on worklist or ignore.
• The IT admin or Fusion guru can determine which payer should be checked for eligibility.
• Fusion checks all incoming charges against the 271 response. Violations are held and surfaced to the Fusion user for validation or correction.
• Fusion checks all incoming charges against the 271 response. Violations, where defined, are auto corrected without user intervention.
• The Fusion user can view and validate or correct 271 failures in a worklist.
• Once the charge has been corrected and no other issues exist on the charge, Fusion releases the claim for billing.

 

Actions are not included for accessions with:

• Any charges where patient is listed as payer.
• Any charges where client is listed as payer.