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Insurance Eligibility Check

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basic instructions: Media:Mmf-batch eligibilityverification.pdf to view the response see the tab next to insurance on the pt's main demographic page trouble shooting tips:

How to use and make corrections for "Report - Eligibility 270 Inquiry Batch".

With your efforts to send the right information, you might get the following from the Clearing house: Remember, it automatically pulls insurance eligibility):

The clearing house an X12 partner: "* Clearing house info required for EDI 270 batch creation".
This is just a warning, you can ignore it.

[[The following link is active for this subject on workflow for this document:

http://sourceforge.net/tracker/?func=detail&aid=3019716&group_id=60081&atid=1245239]]

Problems encountered reporting to clearing houses do implement at least the following:

1) Make a new patient
2) Make a new insurance company
3) Make an X12 partner
4) Add correct insurance to the patient's primary
5) Make an appointment for today
6) Go to Report and put info about anything basically and the date of today
7) Hit refresh and the patient will show up
8) Choose the correct X12 Partner
9) Click: 'Create Batch' and send the text file via X12 while using Availity.
problem encountered could be: Duplicate Interchange Control Number (Means failed)

Response of Availity: We are getting duplicate control number.

There can be some programming issues with eligibility:
1. Control number sequence increment
2. Selected Receiver ID Qualifier (ISA07) as Duns, but it generates file content as ZZ (instead of 01).
3. Application Sender Code (GS02)This value is picked from Receiver ID (ISA08).
N.B: Availity guidelines are in page 29 of http://www.availity.com/documents/edi_guide.pdf.


Other problems encountered:

1. Report lists only patients that have had appointments in the calender. I see the sense in this, so you can check eligibility of up-coming patients, but not all our clients are scheduled in the EMR most of them are never on the calender. It would be nice to check eligibility across the board.
2. Selecting an X12 partner does not restrict the list to just the insurance companies using that X12 partner. Also, with no check boxes/radio buttons, you must "delete" each item in the list individually to edit them from the generated list.
3. Provider for the eligibility check seems to be from the calendar as well. There is sense in this and understandable, is there is a simply way for checking for eligibility against the facility NPI instead of against a particular billing provider, as the provider on the calendar might very well not actually be the billing provider.
After these fixes you will still encounter the same errors from Availity.

These are the X12 settings for X12 PARTNER, we get at this point:

AVAILITY ID: "EIN" RECEIVER ID QUALIFIER (ISA07):Duns (Dun & Bradstreet) RECEIVER ID (ISA08):030240928 SENDER ID QULAIFER(ISA05):Mutually Defined SENDER ID(ISA06): AV09311993 ISA14:Yes SUBMITTER EDI ACCESS NUMBER(PER06):V07432 VERSION:004010X098A1 PROCESSING FORMAT: standard

Question: Am I missing anything? Has anyone successfully submitted an eligibility request to Availity?

Other errors mentioned by Availity might show: (not related to OEMR)

AVAILITY TA1 INTERCHANGE ACKNOWLEDGEMENT Customer ID: 0023558 File Status: REJECTED Date Received: 2011-04-16 Time Received: 15:20:14.435 Filename: elig-270..2011-02-01.2011-04-16.txt File Control Number: 895446777 ******************************************************************************** Interchange acknowledged: TA101 ******************************************************************************** Interchange Date: 110416 Interchange Time: 1514 Interchange Status: The Transmitted Interchange Control Structure Header and Trailer are Rejected Because of Errors. Interchange Note: Unknown Interchange Receiver ID------ END OF REPORT ----------------

N.B: Sometimes you need to call and find out what is necessary to correct.


This might be a good hint as to what goes wrong:

ISA*00*0000000 *00*0000000000*ZZ*AV09311993 *01*AV09311993 *110416*1514*U*00401*895446777*1*P*:~GS*HS*AV01101957*030240928
(Lots of zeros.....Not good. should be blank spaces.)

ISA01-04 ARE used by some companies, and should be made configurable in OpenEMR.

The nes files include a new edit html that allows to configure X12 partner data with the elements in ORDER, instead of any mismatched mishmash order that can be encountered.

Now it is possible to allow configuration of the whole header.

To use the 270, the new X12 partner variables this might provide OEMR with a complete new system.

As per the standard, the Zeros in the interchange header segment are valid if no information is present for that data element (e.g. ISA01-04). (If needed this can be made configurable.)

It is also possible to see an interchange note in the "AVAILITY TA1 INTERCHANGE ACKNOWLEDGEMENT Report": Interchange Note: Unknown Interchange Receiver ID could be the cause of error.

To find any error, it helps to make a print screen. It helps resolve the ISA Errors.

Following GS Errors as an example:
Below are default settings GS01 (Functional ID Code):HS GS02 (Sender Identifier):AV09311993 GS03 (Receiver Identifier):030240928 GS08 (Version): 004010X092A1 GS04 (Date):CCYYMMDD GS05 (Time):HHMMSS GS06 (EDI Group Control Number):000000002

N.B. Reviewing the Availity EDI Guide: The batch generarted by OpenEMR does not create an GE segment.

Availity does accept OpenEMR's eligibility request (270) (Unfortunately OpenEMR is unable to read the (271) reports generated by Availity.)


Following are the necessary changes to make: (in order for OpenEMR generated batch to be accepted, use EDI Notepad to make the changes)

Item : Default Value : Correct Value Receiver Qualifier : ZZ Mutually Defined : 01 Duns (Dun & Bradstreet) Sender Identifier: AV09311993 : AV01101957 Time : HHMMSS : HHMM