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Eligibility (article)

Summary:

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.

Columns:

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

Instructions:

Go to Financial > Eligibility

Filter for something like “Insurance Co. Like: Is Not Empty” to view all clients with insurance. You can also filter for a specific insurance company or other fields (columns) in the Eligibility area. You may also want to filter for only those clients that have an upcoming appointment in a certain date range.

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.

Use Case:

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.

Related Articles:

If you cannot find what you need in this article, please contact Support (email) or call 877.334.8512 ext. 3.

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