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Medical Coverage Eligibility Lookup Cheat Sheet (DRAFT) by [deleted]

Medical Coverage Eligibility Lookup

This is a draft cheat sheet. It is a work in progress and is not finished yet.


Your facility can save signif­icant admini­str­ative time and expense by electr­oni­cally performing routine functions, such as verifying patient eligib­ility and contacting the health insurer about the status of a claim. Access the educat­ional resource “

Unders­tanding the HIPAA standard transa­ctions: The HIPAA Transa­ctions and Code Set rule” to learn about the HIPAA electronic standard transa­ctions, the HIPAA Transa­ctions and Code Set rule and how this rule impacts your practice

Multiple search options

The eligib­ility request and response transa­ctions provide the following options and patient inform­ation to assist you with obtaining and utilizing accurate patient inform­ation:

Required Alternate Search Options (all health plans support)
• Member ID, Date of Birth, Last Name
• Member ID, First Name, Last Name
Recomm­ended Alternate Search Options (many health plans support)
• First Name, Last Name, Date of Birth
• Member ID, Date of Birth
Inquiry dates
• Single Date Type Request (Plan Date)
Expanded health plan details
• Plan begin date
• Plan end date, if establ­ished
• Plan name
Patient identi­fying inform­ation
• Correct demogr­aphic inform­ation needed by the health insurer for other transa­ctions like the ASC X12 837 health care claim: profes­sional and ASC X12 278 health care services review inform­ation (refer­ral­/au­tho­riz­ation inquiry).
High level benefits
• Active coverage for any of the following: Medical Care, Chirop­ractic, Dental Care, Hospital, Emergency Services, Pharmacy, Physician Office Visit, Vision, Mental Health, Urgent Care
Other entities
• Primary Care Provider
• Other Payers

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (ACA) required that all health insurers support requir­ements of the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Inform­ation Exchange (CORE) 5010 Phase I & II Operating Rules by January 1, 2013. Many health plans already support the CAQH/CORE Phase I & II Operating Rule requir­ements. Visit http:/­/ww­w.c­aqh.or­g/C­ORE­_or­gan­iza­tio­ns.php to see if the health insurers are on the list

Operating rule requir­ements include:

The patient’s portion of the financial respon­sib­ility must be returned (co-pa­yment, co-ins­urance and patien­t-s­pecific remaining deduct­ible) for the following service type codes.
33 – Chirop­ractic
47 – Hospital
48 – Hospital Inpatient
50 – Hospital Outpatient
86 – Emergency Services
98 – Profes­sional (Physi­cian) Visit
UC – Urgent Care.
The health insurer may, at its discre­tion, return copayment, coinsu­rance inform­ation and base deductible inform­ation for the following services specified in EB03-1365:
01 – Medical Care
30 – Health Plan Benefit Coverage
35 – Dental Care
88 – Pharmacy
AL – Vision (Optom­etry)
MH – Mental Health
If the patient’s portion of financial respon­sib­ility differs for in and out of network, both must be reported.
Inquiries for dates 12 months in the past and to the end of the current month must be supported.
Explicit requests must be supported for service type codes
01 – Medical Care
33 – Chirop­ractic
35 – Dental Care
47 – Hospital
48 – Hospital Inpatient
50 – Hospital Outpatient
86 – Emergency Services
88 – Pharmacy