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Welcome to the RUG n’ Roll Midwest & Great Lakes Regional User Group for Cerner Clients Eligibility Management. Milwaukee, Wisconsin April 30 – May 2, 2007. Presenters:. Sue Tallar – Aurora Health Care Supervisor, Patient Access Team Heather Maki – Aurora Health Care

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Welcome to the RUG n’ RollMidwest & Great Lakes Regional User Group for Cerner ClientsEligibility Management

Milwaukee, Wisconsin

April 30 – May 2, 2007


Presenters
Presenters:

Sue Tallar – Aurora Health Care

Supervisor, Patient Access Team

Heather Maki – Aurora Health Care

Business Application Analyst, Patient Access Team


In the next 50 minutes
In the next 50 minutes...

  • What is Eligibility Management

  • Advantages & Concerns

  • Set Up

  • Integration with ERM & Scheduling


Who is aurora health care
Who is Aurora Health Care?

  • Private, non-profit, teaching organization:

    • - 664 employed physicians

    • - 3,385 physicians on staff

    • - 25,000 employees

    • - $3 billion annual revenue

    • - 0.5 million IP days/year

    • - 2.4 million OP visits/year

    • - 0.25 million ED visits/year

    • - 0.3 million Home Care visits/year

    • - 5.6 million retail Rx/year

  • Integrated Delivery Network

    • 13 Hospitals (60-800 beds)

    • 120 Outpatient Clinics

    • 140 Retail Pharmacies

    • Long Term Care

    • Home Health Services

    • Hospice Services

    • Laboratory Services

    • One of the nation’s “Most Wired” hospitals in 2004, 2005, 2006


Eligibility management
Eligibility Management

Facilitates the electronic processing of insurance eligibility verification through electronic data interchange. By automating these transactions, insurance eligibility can be verified in real time.


Eligibility and erm integration
Eligibility and ERM Integration

  • Eligibility Check May be Performed at the Time of Pre Registration or Registration

  • Eligibility Validation Button in ERM Conversations


Eligibility management1
Eligibility Management

  • Eligibility performs a simple check on the insurance eligibility status of a patient

  • This allows for the verification of insurance prior to the procedure, or if desired it can be verified before a procedure is scheduled

  • Requests are sent directly to an insurance payer or to a third party clearinghouse


Eligibility management2
Eligibility Management

  • The payer or clearinghouse returns a response that includes eligibility info

  • Response may be viewed from Scheduling and Registration or in a stand alone tool


Advantages
Advantages

  • Reduce number of denials due to patients having inactive coverage

  • Eliminates having to re-enter patient and insurance information into a separate application. Less chance of human error

  • History of previously ran transactions is retained, no need to re-run the eligibility check


Concerns
Concerns

  • Anyone who has access to ERM pre-reg will have access to send eligibility through

  • When using a clearinghouse there is a charge if results are posted. If insurance is not set up in Cerner, users will not get a response back, therefore no transaction fee

  • No multi-facility logic supported in application. We get around this by using one facility ID for all eligibility transactions


Setting up eligibility management
Setting Up Eligibility Management

  • 3rd party clearinghouse or direct connection. Must have contract negotiated with payers or clearinghouse(s) for processing

  • 270/271 HIPAA compliant Interface

  • EEM Profile tool

  • Icons placed in ERM conversations


Building profiles
Building Profiles

  • Profiles need to be built for each Payer in EEM Profile tool

  • 270 transaction initiated in Cerner, which is then sent outbound to clearinghouse

  • Clearinghouse will send the EDI information to the payer that is required to process transactions


Submitting transactions
Submitting Transactions

  • Via ERM

  • Via Standalone

  • Via Scheduling


Submitting via erm
Submitting via ERM

  • After insurance info is verified in ERM, user clicks on the “Eligibility Validation” icon to open Eligibility Validation window

  • All insurance plans will display


Eem previous history
EEM Previous History

  • History on previously submitted transactions is stored. Before submitting transactions, history is viewed to see if a transaction had been submitted

  • History on previously ran transactions is saved until purge job is ran.



Submitting a transaction
Submitting a Transaction previously ran

  • After insurance info in ERM is verified, user clicks on the “Eligibility Validation” icon to submit transaction. Insurance is selected and submitted to clearinghouse


Details that are returned vary depending on the Payer, each Payer determines what to send back. The information displayed can also be printed  Eligibility Details shows if patient has active coverage


Submitting via standalone
Submitting via Standalone Payer determines what to send back. The information displayed can also be printed

  • Icon is placed on the Cerner Desktop

  • No encounter is needed to submit transactions

  • Insurance information submitted comes from what was last entered in ERM


Information from erm populates transaction is submitted
Information from ERM populates, transaction is submitted Payer determines what to send back. The information displayed can also be printed


Eligibility standalone response info
Eligibility Standalone – Response Info Payer determines what to send back. The information displayed can also be printed


Submitting via esm
Submitting via ESM Payer determines what to send back. The information displayed can also be printed

  • Automatic verification at

    • Booking

    • Check In

    • Reschedule

  • Manual Verification

    • Right click – Actions – Verify

    • Verify Button


Esm confirm window
ESM Confirm Window Payer determines what to send back. The information displayed can also be printed

Eligibility Status


Esm confirm window eligibility tab
ESM Confirm Window/Eligibility Tab Payer determines what to send back. The information displayed can also be printed

Eligibility Details


Enterprise eligibility esm icons
Enterprise Eligibility & ESM Icons Payer determines what to send back. The information displayed can also be printed

Appointment Icons available

Icon will display when check is performed


Enterprise eligibility esm history
Enterprise Eligibility Payer determines what to send back. The information displayed can also be printed ESM History

Eligibility status shows verified


History cont
History (cont.) Payer determines what to send back. The information displayed can also be printed

Action History shows who checked Eligibility

Benefit information displays


Questions
Questions? Payer determines what to send back. The information displayed can also be printed


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