Insurance Eligibility Check

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How use "Report - Eligibility 270 Inquiry Batch".

While implementing all the efforts the send the right information you might get from the Clearing house:

Remember, it automatically pulls insurance eligibility. The clearing house an X12 partner, is giving this error in red "* Clearing house info required for EDI 270 batch creation".

This is just a warning, you can ignore it. Refer the following link for workflow document:

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

The same problem is compiled as follows:

1) Made a new patient

2) Made a new insurance company

3) Made and X12 partner

4) Added insurance to the patient's primary

5) Made an appt for today

6) Went to the report and put date from (anything basically) and to today

7) Hit refresh and the patient showed up

8) Then choose an X12 Partner

Click: 'Create Batch' and send the text file via x12 stuff while using Availity.

First 2 times I missed ISA06 and GS02. (Means: failed)

Third time Interchange Note: Duplicate Interchange Control Number (means failed)

Response of Availity: They 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 some fixes there still might be the same error from Availity.

These are the X12 settings for X12 PARTNER: 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? What other errors might Availity 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 ---------------- Their system will be down from 16apr 1700- tomorrow. Sometimes you need to call and find out what is necessary to correct. This might be a good hint as to what is screwy: 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 configurable in OpenEMR. These are modified files for claims and x12 partner configuration:

http://starfrontiers.org/khvcode/Openemr/x12_header_mod.zip

Part of these 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. Also possible to allow configuration of the whole header. Compiled: There is need for sql-queries patch updates. Have the 4.1 upgrade added as well (probably the 3.2 upgrade also). Have to use the 270 the new X12 partner variables this might provide OEMR with a complete new system. Advise: Could utilize my files to make changes here, and allow these values to have configurable settings. Without such, I won't (and a lot of folks in Fl &IL won't) be able to use it for everyone. Once this is done, I believe a lot of recurring issues will be solved. You could integrate my includes, use those fields/variables the way I have done in my x12 gen changes. 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. Could be an error in the header segment information OR any other issue. To find any error it helps to make a print screen. It helps resolve the ISA Errors.

Following GS Errors might give some ideas:

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

While reviewing the Availity EDI Guide it is clear there is no GE segment in the batch generated by OpenEMR.

After numerous submissions, I finally got Availity to 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