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Eligibility Verification
An eligibility verification
and benefit inquiry permits a provider to determine if a patient is currently
eligible for coverage from the selected payer. Inquiries can be submitted through
Medisoft or Lytec and can be submitted in batch files or individual requests
for real-time processing and in a matter of seconds, receives a standardized
response with the payer's information.
Details
The data in an eligibility response can vary by payer, plan type or other variables.
Typically responses include such information as patient/recipient information,
coverage status and effective dates, plan name, plan type, PCP information,
responsible medical group and detailed benefits. Benefit information can include
inpatient and outpatient benefits, pharmacy benefits, deductible accumulation,
co-payment accumulation, stop-loss information, waivers and restrictions, etc.
Because the provider is getting the most current eligibility and benefit information
from the payer, the provider can make intelligent decisions about service and
payment arrangements.
More Information
The standardized response provided to MedUnite users is based on the ANSI X12N
Eligibility Response from each health plan. Designed to comply with HIPAA standards,
they provide critical insurance coverage data, including:
- Coverage dates and status,
which tells you whether a patient has insurance coverage on the date(s) that
you are providing care;
- Patient co-pay responsibilities
that give you the correct co-payment while the patients are in the office
for their visits, not afterwards;
- Details on patient's
medical group affiliation that help you to submit claims to the appropriate
party when risk has been shifted away from the health plan;
- Name and address of primary
care provider identifies who the health plan has listed as the patient's primary
care provider and how to contact them.
To get more information
click here
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