Set Up Batch Eligibility

When want Electronic Eligibility set up, your Business Analyst (BA) will set up manual eligibility verification first. It should run successfully for two months.

After two months, Batch Eligibility can be set up and started in the “Train” environment and run for several months to verify the process consistently completes successfully. After the successful “Train” phase, your Batch Eligibility can go live.

The Process to Set Up Batch Eligibility

Gather Information

Identify Plans for Verification

Gather Information

To begin implementation, the BA must gather requirement information from the customer. The following information is needed:

1.      Identify whether the customer uses any electronic verification currently.

a.       If so, can the connection information be re-used for Electronic Eligibility?

2.      Identify the plans to verify eligibility.

3.      Identify the plans to be automatically updated.

4.      Identify the plans to remove based on the 271 response.

5.      Identify any custom information to include in the request or the response file. For example, the customer may want to provide the specific county of treatment.

6.      Identify the coverage plans that provide Medicaid Spenddown information.

7.      Identify how to handle spenddown information:

a.       Insert Unknown records when no data is returned for date met, but 271 indicates a spenddown.

b.      Insert Date Met when data is returned for “date met” by the 271.

8.      Identify COB order for all coverage plans.

Note: Every plan in SmartCare must be ranked for COB, even if the plan will not be electronically verified.

9.      Identify the reports that are needed.

Identify Plans for Verification

When you know which plans the customer wants to verify, then you need to determine how to connect electronically to each plan. The plan may provide connection or may require the provider to send the 270 to a clearinghouse for verification.

Registration with the Payer

• Typically, the customer registers with the plan or clearinghouse.

• Streamline may need to register as a “software vendor” with the provider.

Technical Requirements to Set Up Individual Electronic Eligibility

For Individual Electronic Eligibility, the following is needed:

• o    Web Service URLS, preferably SOAP
• ·         Streamline also supports TCPIP.
• ·         Other types of connections are possible, but may require extra development time.
• o    Submitter IDs, where necessary
• o    Web Service Usernames
• o    Web Service Passwords

·        

Technical Requirements to Set Up Batch Eligibility

 For Batch Eligibility using FTP:

o    FTP URL, password and username for batch implementation is needed.

·         For Batch Eligibility using Web Service:

o    ??? for batch implementation is needed.

·         270/271 companion guide(s)

·         Other connectivity guide information, such as SOAP implementation guide, when available.