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Welcome to the RUG n’ Roll Midwest & Great Lakes Regional User Group for Cerner Clients Eligibility Management

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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


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
  • 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
  • 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
  • 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
  • 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
submitting via esm
Submitting via ESM
  • Automatic verification at
    • Booking
    • Check In
    • Reschedule
  • Manual Verification
    • Right click – Actions – Verify
    • Verify Button
esm confirm window
ESM Confirm Window

Eligibility Status

enterprise eligibility esm icons
Enterprise Eligibility & ESM Icons

Appointment Icons available

Icon will display when check is performed

enterprise eligibility esm history
Enterprise Eligibility ESM History

Eligibility status shows verified

history cont
History (cont.)

Action History shows who checked Eligibility

Benefit information displays