Insurance Eligibility Verification is the process of verifying a patient’s insurance eligibility for health care services, as well as determining the patient’s co-pay and remaining deductible before services are rendered. verifying insurance eligibility and coverage helps the facility communicate financial expectations to the patient, ultimately minimizing the risk of uncollected balances.
Verification of insurance eligibility can be done during the admission process, or it can be done outside of the admission process for single patient scenarios. The application received results and retains the details of the verification request.
The 270 and 271 transaction records refer to the information that is sent and received.
270 - The information that is sent
271 - The information that is received
Below is the required system configuration in order to utilize Eligibility Verification:
Centriq Financial applications in use.
High-speed internet connection.
270 Trading Partner: The 270 transmission type in Insurance Processing > Trading Partners > 270 Info tab must be set to the correct format (5010 version).
Verify that your facility's NPI is entered in Patient Registration > Master Files > Facilities.
Insurance carriers are set up with the correct Eligibility Verification information in Patient Registration > Master Files > Insurance Companies > Eligibility Info tab.
User roles are allowed access to MPI Check Eligibility in Centriq Administration.
See the Centriq Third Party Products Setup Guide located on CPSIQ for step-by-step instructions on how to set up Eligibility Verification.
Currently, all facilities, such as hospital, Long Term Care, and Home Health, require only a single registration with Emdeon or Rycan. NOTE: Emdeon is used for the v5010 format only.
Contact Centriq support for an official list of payers. Contact your Account Manager for more information.
In the Registration window, search for and select the patient and click the Edit MPI button. The Edit Master Patient Index window is displayed.
Click the Check Eligibility button at the bottom of the window. The Eligibility Check window is displayed with a list of all insurance(s) carried by the patient. [+]
See below for a description of each column in the grid:
Transmit - This check box is used to select the payers to include in the eligibility verification. (NOTE: Only those payers set up as eligible for Emdeon checking can be selected.) The Transmit box is selected by default based on the Active (Yes) and Eligibility Checking Frequency as set up in Master Files > Insurance Companies > Eligibility Setup tab. Frequency setup affects verification checking in these ways:
Check Date of Service - Checks if the system date = service date
Good for the Month - Checks if the system date's month is not within the same calendar month as the date the insurance was last checked.
Good for the Year - Checks if the system date's year is not within the same calendar year as the date the insurance was last checked.
Always Check - Always checks independent of the last date insurance was checked.
Payer/Insurance - Insurance as entered on the Patient Insurance tab of the Add/Edit MPI window.
Last Checked Date - Displays the last date that the insurance was verified.
Notes - Displays a verification code to indicate whether or not the payer needs verification (based on the legend located at the bottom of the screen).
G=Do not SEND, already verified this month or year
O=Only SEND on Date of Service
A=Always SEND for Verification
The Subscriber ID # and Group # must be entered on the Patient Insurance tab. If not entered, a message is displayed (after clicking the Check Eligibility button) stating there isn't enough information to check eligibility.
Indicate the payers for verification by checking or unchecking the Transmit box for each insurance.
Click the Check button at the bottom of the window. The Check Eligibility window is displayed. [+]
In the Trading Partner field, click the Find button to access the Trading Partners inquiry screen and select the trading partner for checking eligibility. (NOTE: Trading partner is set up for the 5010 format.)
In the Type field, select whether verifying a Facility or a Physician.
If verifying a physician, the Physician Type field is displayed. Use the drop-down list to select the physician's type:
AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital (default selection)
OT Other Physician
If verifying a facility, the Facility field is displayed. The default facility is displayed if set up in the Trading Partner master file (in Insurance Processing). ALWAYS verify the correct facility is displayed before proceeding with the eligibility check. To edit, click the Find button to access the Facilities inquiry screen and select the appropriate facility.
In the Date Type field, select Issue or Plan. NOTE: This field is required in order to transmit service dates.
In the From Date and To Date fields, specify the time frame (service date range) you want to include in the verification.
Select Service Type or Procedure Code based on the criteria to include in the insurance verification. NOTE: The Procedure Code option is not available for Rycan eligibility verification.
Choose from the following options:
If Service Type is selected, the Service Type panel is displayed. Check the boxes of the service types to include in the insurance verification, or check the Select All box to include all service types. The Select All box is disabled when over 99 service types are displayed (see note below).
There are 180+ service types
available for selection. To save time during the verification process,
the 270 Service Types tab in Insurance Processing > Master Files
> Trading Partners can be used to select the service types that
are most commonly used by your facility to appear in the Service
Type panel for potential verification, and indicate whether or
not to default them as selected for verification. You can toggle (check/uncheck)
the service type check box settings in the Service
Type panel as needed.
Up to 99 service types are allowed to pass in the 270 transaction set.
If over 99 service types are selected, the message, Maximum
number of selected service type exceeds the limit of 99, is displayed
upon clicking the Check button.
Click OK and adjust the Service
Type selections to be 99 or less.
If Procedure Code is selected, the Procedure Codes panel is displayed. Click the Add button to display the Add Procedure Code window. Enter the following information:
In the Procedure Code field, click the Find button to search for and select the procedure code to include in the insurance verification.
In the Modifier 1 and Modifier 2 fields, click the Find button to search for and select the appropriate modifiers for the procedure code.
In the Diagnosis Seq # field, enter the numerical sequence.
Click Save. (Repeat steps A-D for each procedure code to include in the insurance verification.)
In the Service Provider No. field, enter the service provider number (up to 20 characters).
In the Place of Service field, use the drop-down list to select the place of service.
In the Diagnosis Codes fields, click the Find button to access the Diagnosis Code inquiry window. Search for and select a diagnosis code to include in the insurance verification. Up to 8 codes can be entered.
When selecting an ICD-10 diagnosis code, the following data elements are validated against the episode's diagnosis; one of the following warning messages will display if the selected diagnosis doesn't match the episode data.
Data Element |
Warming Message |
Gender |
Gender of Diagnosis Codes does not match gender of patient. |
Newborn |
Newborn Diagnosis Code for patient over one year old. |
Age |
Patient age is less than Diagnosis Code minimum age - min age. |
Age |
Patient age is greater than Diagnosis Code maximum age - max age. |
Click Check. The 270 transaction set is generated and sent to the trading partner (e.g., Emdeon) for verification. The Eligibility Details window is displayed. [+]
Select the following options as needed:
Click the Details button to display the Eligibility Information. Click on the appropriate tab to view the corresponding information.
The Eligibility Information tab displays the eligibility data from the 271 file. NOTE: Any errors (code and description) from the 271 are displayed here along with the follow-up action code and description.
The 270 Request tab displays the formatted data transmitted in the 270.
The 271 Response tab displays the formatted data transmitted in the 271.
Click the Print 270/271 button to view and/or print the 270 request and 271 responses in report format.
Click the Print Eligibility button to print the eligibility request.
Click OK to continue. If more than one insurance was selected, the transmission process continues with each insurance until all selected transmissions are completed. Once the last transmission is completed, you are returned to the Eligibility Check grid. The Last Checked Date and Notes information is updated in the grid, and the History window is updated with the last checked date.
Click Cancel to exit the Eligibility Check window and return to the Edit Master Patient Index window.
On the Eligibility Check window, click the History button. The Eligibility Check History screen is displayed.
A list of transactions is displayed in a grid with the most current transaction listed at the bottom. The grid includes the insurance, trading partner, facility, physician, and last checked date. Select a line item to view.
Click View Eligibility Details. The Eligibility Details window is displayed as described above.
