Posts Tagged ‘claim status’

New & Improved Eligibility Checks In 2013

In Uncategorized on August 23, 2013 at 5:30 pm

Over the years, M.E.D.I.C. has consistently advised that its clients run eligibility checks of all patients to ensure that they have valid insurance coverage, and are eligible to receive the services that are being sought.  In providing such advice, M.E.D.I.C. has also attempted to be diligent in alerting clients to the fact that the eligibility information received back from carriers would not be uniform…  that while some carriers may respond with a plethora of data, which may include patient eligibility, his/her co-pay, deductible, deductible remaining, co-insurance, etc…, others may provide a mere yea or nay on eligibility.  As of January 1, 2013, that has changed, as detailed in the article below, which has been reprinted with permission of the American Medical Association (AMA) and the Healthcare Billing & Management Association (HBMA) (emphasis added).

Take Advantage of New Eligibility & Claim Status Enhancements

Since the beginning of 2013, health insurers have been required to send robust information to physician practices and their billing partners that use the eligibility and claim status electronic transactions.  When responding to these [eligibility and claims status] queries, health insurers must report the co-payment, remaining deductible, and co-insurance for each specific procedure or service (i.e., CPT/HCPCS code) for both in-network and out-of-network services. The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) eligibility and claims status Phase III Operating Rules rules were adopted under the July 8, 2011 HHS rule, “Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions; Interim Final Rule.” This rule requires health plans to include robust patient financial information on eligibility responses by January 1, 2013. CAQH CORE Operating Rules are based on principles similar to those that govern ATM networks and direct deposit banking in the banking industry, as well as those that maintain and facilitate electricity flow in the power industry.1

These new enhancements offer physician practices and their billing partners the opportunity to determine the amount that a patient will be responsible to pay – while the patient is still in the office – and accept payment from patients at the point of care. Electronic eligibility verification and claim status now provide the patient’s co-payment, co-insurance, and remaining deductible amounts.

Resources on Eligibility and Claim Status Electronic Transactions
The American Medical Association (AMA) offers a number of resources and how-to toolkits about using the eligibility and claim status electronic transactions – and more!

  • Toolkits and archived webinars provide step-by-step guidance on using electronic transactions, including eligibility and claim status. Visit to access resources on electronic eligibility verification, claim status, claim submission, prior authorization/ referrals, electronic remittance advice, and electronic funds transfer.
  • The AMA also offers a toolkit and related, archived webinars to help you get payment from patients before they walk out the door. Visit to access how-to resources on using eligibility verification information to determine the amount a patient will be responsible to pay and on accepting patient payment at the point of care.
  • Join the AMA’s “Heal the Claims Process”™ campaign. The campaign’s goal is to reduce the cost of managing the claims revenue cycle from as much as fourteen percent of revenue to just one percent so physician practices and their billing partners can spend less time with paperwork. Visit to learn more about the campaign and pledge your organization’s support.
  • Practice Management Alerts provide access to new practice management resources and tools. Sign up for free AMA Practice Management Alerts at to stay up to date with new resources. These timely e-mail alerts also provide updates on unfair payor practices and ways to counter them.
  • The AMA’s Paperless Practice Group online community offers a place for physician practices, billing partners, and other healthcare stakeholders to take part in peer-to-peer discussions. Join this online community to find out what is working for your peers and share your own success stories about streamlining your claims processing. Visit today!

If you are not running eligibility checks, you may be leaving money on the table!  Start today – and feel free to contact M.E.D.I.C., Inc., at any time to discuss any questions that you may have implementing such systems.

1 CAQH CORE. CAQH Committee on Operating Rules for Information Exchange (CORE) FAQs: CAQH CORE Eligibility & Claim Status Operating Rules/Policies. (Version 20121002.1001) Accessed October 30, 2012.