Did you know CPR+ includes an Electronic Eligibility Inquiry feature for major medical payors & Medicare Part D payors that can be performed for a new customer or an existing customer? For major medical payors, the response can include deductible amounts, out-of-pocket amounts, percentages of reimbursement, and more. For Medicare Part D, this verification can assist in the challenge of determining which PDP (Pharmacy Drug Plan) a Medicare beneficiary is enrolled in.

Medicare Part D E-1 Eligibility Check

Let’s start with Medicare Part D E-1 Eligibility Check. The E-1 is a special NCPDP transaction that is sent to NDCHealth. This company, chosen by CMS, maintains up-to-date information on all enrolled Medicare beneficiaries and their chosen PDP's. The E-1 response identifies which PDP the patient is enrolled in and alerts you immediately.

The Eligibility Check window can be accessed by clicking the icon
located in the areas listed below:

• the CPR+ Toolbar
• the Patient Information window
• the Insurance Verification window.

This displays the Check Eligibility window.

Select Medicare Part D

While on this window, you can check the eligibility for an existing patient in CPR+ or you can enter a new patient. In addition, you can select the type of E-1 check from the drop-down list in the Type field.

New or Existing Patients:

In the case of an existing patient, key information is passed from Patient Demographics to the fields on this window. Click the Check For Elig. (F2) button to view this patient's eligibility for Medicare Part D. CPR+ looks at the response data and tries to find a match on the BIN/PCN to determine if this payor already exists in the Insurance Company database. If there is a match, the information can be added directly to the patient's record.

Unlike the existing patient, the fields on the Enter Eligibility Information window are blank when working with a new patient record. You must have the patient's Name, Date of Birth, Sex, Zip Code, and Cardholder ID. The Cardholder ID can be the actual ID Number or the last 4 digits of the patient's Social Security Number. Click the Check For Elig. (F2) button to send the E-1 transaction.You now have the ability to add the patient, the Payor Group, and ID Number into CPR+ by clicking the Add Patient to CPR+ (F11) button.

If the response contains a Payor that is not currently loaded into CPR+, you can click the WebMD Reference Sheet (F8) to see the payor specifications and to add the payor to CPR+.

*** Post-Publication Note: In the paragraphs below, it is mentioned that Wellpoint can be billed for a 14 day supply if a positive response is received for a Medicare Part A/B Eligibility (Expanded) check. This program is no longer in effect as of 1/1/2010. Additional information can be found at this link: http://www.humana.com/pharmacists/resources/li_net.asp.
The message box will be changed in a future release of CPR+.***

If the E-1 Eligibility (Part D) does not return a response, you will select the E-1 Expanded Eligibiltiy (A/B). From this check, you will receive a positive or negative response. There are no eligibility results returned with this process.

• When a response is negative, CPR+ displays a message stating that the response was negative and the following text, "According to Medicare's Part AB Eligibility document, a negative response indicates the beneficiary coverage cannot be confirmed."
• When a response is positive, CPR+ displays a message stating that this response was positive and the following text, "According to Medicare's Part AB Eligibility document, a positive response indicates the following:
  
  
  • 1) The pharmacy bills the WellPoint Facilitated Enrollment Plan (BIN/PCN=610575/CMSDUAL01) for a 14-day supply of the drug. (This is supposed to trigger the enrollment of the beneficiary into the proper PDP.)
  • 2) At some time in the future, the pharmacy reverses the claim to WellPoint and bills it to the appropriate PDP. (May require another Part-D Eligibility transaction.)

Great stuff, right? But there’s more!

270 / 271 Electronic Eligibility Inquiry

270 / 271 Electronic Eligibility Inquiry does require enrollment. You can enroll your company for Electronic Verification by calling CPR+ Customer Support at 877-277-4876. Just ask for “Enrollment”.

270 / 271 Electronic Eligibility Inquiry also requires some setup in CPR+ before you can begin.

Company Setup

From the Main Menu, select Utilities (8) > Site / Company Setup (1). Select the Electronic Billing Info tab and then Edit 270 Options. During the enrollment process, you will be given a TID. Enter that number in the TID field on this window.

Insurance Database Setup

To begin the next step, select Databases (7) then Insurance Companies (4). Select the payor, then go to the Setup Options (F5) tab. Select the 31+ sub-tab (or 21+ in version 8.1 and earlier releases.) Now select Edit 270 Options. Enter the payor ID in the Payor ID field.

Before explaining the fields on this window, let me explain why this information might be needed by a payor for eligibility information.
Since the 270 is basically an Electronic Eligibility Inquiry for major medical payors, the fields on this window must be completed based on how the payor wants to receive them. The 270 inquiry and the corresponding 271 Report are essentially ANSI-approved formats; however, the information requested is different from payor to payor.
Depending on the payor, they might return an eligibility response based on:

• Payor ID and Patient Name, or
• Payor ID, Patient Name, and DOB, or
• Payor ID, Patient Name, DOB, and Service Date, and so on.
  

Based on these payor-requested variables, there are two groups of checkboxes located in the lower portion of the window. The box selection tells CPR+ what fields to populate from the patient information on the 270 electronic form window. For most payors, all of these fields are selected.

With all of the fields completed based on the payor requirements, click the Save (F2) button and then proceed to click the Eligibility Check icon for those patients with this payor.

After selecting the 270 / 271 radio button and clicking the Continue (F2) button on the Check Eligibility window, you are presented with a window with two options: Existing Patient and New Patient. Make a selection and click the Continue button. If this is an existing patient, select the patient (from a list displayed on the window) and then select a payor assigned to the patient.

NOTE: For an existing patient, only those payors set up for 270 / 271 eligibility checks will appear in the Select the Payor list even though this patient may have more associated payors. In addition, the 270 / 271 payors will appear with the associated ranking related to this patient.

After selecting the appropriate payor, the following window is displayed:

On the Create 270 Eligibility Check window, you will be presented with the fields completed for an existing patient or a blank window for a new patient. Enter or verify the information on the Basic Info tab.
NOTE: For a new patient, select the payor from the Payor pop-up. Only those payors that are set up for 270 eligibility checks will appear in this list.

If the Dependent Info section is completed based on the Payor’s 270 Options, but is not needed for this eligibility check, simply uncheck the Transmit checkbox.

NOTE: There are payors that require dependent information. In this case, and if the patient is the dependent, CPR+ will populate the patient’s information in both the Subscriber and Dependent Info sections. This scenario will require the Transmit checkbox to be unchecked.

Notice that there is a Service Date range in both the Subscriber Info and Dependent Info sections. The Service Date field is already completed with today's date when opening this window, but the To field is blank. Depending on the payor, they may want to see a date range for this eligibility check. You will need to manually complete the To field for those payors before sending. Otherwise, the eligibility will include only the Start Date and will be rejected by those payors that require a date range.

NOTE: If the default Card Issue Date box is checked within 270 Setup Options for the Payor (located in the Auto-Populate Subscriber Fields section), the Effective Date entered for the patient's insurance is populated in the Card Issue Date field. This feature was specifically added for Medi-Cal.

Before moving on to the next tab, verify the Service Type Code field. This field is defaulted to 30 (Health Benefit Plan Coverage). Change this setting if required by the payor. Otherwise, leave this field as is.

With the Basic Info tab completed, select the Advance Info tab and the Information Source and Information Receiver sections will be completed based on the selected payor and the provider.

NOTE: The Information Receiver fields on the Advanced Info tab are pulled from the Company’s 270 settings.

With this information completed, click the Send (F2) button and you will receive the patient’s Eligibility Information (271)! Now you can enter the information in the patient’s Insurance Verification.

If you would like to schedule time with one of our expert trainers to learn more about this or any CPR+ topic, contact Kim Carlsen today.

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