The Eligibility area is mainly for creating and sending EDE Type 270 files to your Clearinghouse in order to check eligibility for your clients’ insurance status. The Clearinghouse will use the 270 file to produce a list of the clients submitted and whether they still have valid insurance. You will need to check that list on your Clearinghouse website. There are many items that can be filtered for on the eligibility screen.
Next Appointment –client’s next appointment day/time
Insurance Type –type of insurance: primary, secondary, tertiary
Client – selected client
Client DOB – client’s date of birth
Insurance Co – client’s insurance company
Payer Number – insurance payer number
Group Number – insurance group number
Individual Number – client’s insurance ID number
Effective Date – effective date of client’s current insurance policy
Expiration Date – expiration date of client’s current insurance policy
Name of Subscriber – name of the subscriber – could be a parent or guardian
DOB of Subscriber – date of birth for the subscriber
Insurance Co Phone – insurance company phone number
Insurance Co Email – insurance company email
Insurance Co Contact – insurance company main contact person
Division –default division the client is assigned to.
Client Number – PIMSY client number
Active – client is active in the system
Client Address – client’s address
Subscriber Address – subscriber’s address (see above for subscriber example)
Primary Therapist – client’s current primary therapist
Qualified Professional – client’s current qualified professional
Primary Physician – client’s current primary physician
Primary Diagnosis - client’s current primary diagnosis
Go to Financial > Eligibility
There are two menu items from which to select:
Eligibility Clients - a list of all active clients and their primary insurance eligibility status
Eligibility Waitlist - a list of all waiting list client eligibility
There are radio buttons at the top of the page where you can filter by Primary, Secondary and Tertiary insurance eligibility, as well as Active or all clients.
Once you have the preferred information on the screen, you can create an EDE 270 document right from this area to send to your Clearinghouse. Simply select 270-*** in the EDE Type dropdown field. The EDE Type 271 is the returned clearinghouse file with a list of clients with their insurance status.
A staff member at the ABC Therapeutic Group needs to check insurance eligibility (active policy dates) for all clients with upcoming appointments. From the eligibility area, the staff can filter for appointments to create a 270 file for the Clearinghouse. When they go to the Clearinghouse website, they can check all eligibility for clients sent in the 270 file.
Now, if the client is no longer eligible, the PIMSY staff can request a new insurance card with valid dates when the client arrives for their next appointment. You can use the PIMSY Misc Comments tab area on the client’s chart to help remember to do that.
If you cannot find what you need in this article, please contact Support (email) or call 877.334.8512 ext. 3.