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Eligibility Overview - Coggle Diagram

- - - - Would like a monitoring system for tracking the status of enrollment
        currently done by hand, sql queries
    - - Partner
      - PCC Clearinghouse Eligibility Databae
      - We would like to standardize this info to reduce configuration
    - - ced configuration
        (ecs_rc)
      - PCC EHR Permissions
      - Test it - make sure it works.
    - - Tax ID
        (gen_rc files)
        
        HCFA_list (I_files can also direct to batches)
        (bridges/maps the plan to identify gen_rc file that need to be configured with the Tax ID)
      - NPIs Type 2
        (provider table)
- - - - 270 ASNI X12 HIPAA mandated standard eligibility request
        (General Request for a date of service)
        Partner creates the 270 and sends it to the hub
        The hub may perform some transformations,
        but is mostly sent as is.
    - - rtelig file
        (instructs how to format the 270 requests)
    - - client sees the plan is not configured to submit eligibility requests. This can mean multiple things:
        
        it may not be supported
        
        it may be supported but not configured
        
        it may be supported and configured, but not configured correctly
        
        It would be nice if it showed the nature (to clients and Support) why rtelig requests cannot be made
- - - - see messages on their screen:
        "This insurance plan is not configured for eligibility requests"
        "Unable to respond" (timeout)
        ...maybe other messages...
        (they call PCC)
        (PCC troubleshoots and works with client)
        Policy info may not be complete
        Pt Sex may be missing.
        It would be nice to provide them more info to reduce support calls.
      - pcc receives broadcast emails that elig is broken for an insurnace or clearinghouse
        (example: in 1 day we may get 40 messages from Availity clearinghouse letting know connections are now up or down)
- - - - clients will let us know that they have a payer for which there is no eligibility set up
        (client is being proactive, knowing they added a new payer and want to get eligibility set up right away)
      - PCC is notified from one of our clearinghouse partners that they want us to send ellig requests through them for certain payers
      - Established clients call reporting that eligibility is broken, but in fact it was never set up for them for that payer.
        Clients will add new payers over time and those new payers need eligibility configuration.