A Deep Dive into the rollout of Eligibility and integration
with ETM University of Alabama & Centricity EDI Services April
30, 2015
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The content of this presentation represents the views of the
author and presenters. GE, the GE Monogram, Centricity and
Imagination at Work are trademarks of General Electric Company.
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Introductions Overview of University of Alabama Eligibility
Decisions ETM Integration Design Q&A 3
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University of Alabama at Birmingham Debbie Rickett -
Application Specialist [email protected] Roberta White Lead System
Analyst [email protected] GE Healthcare IT EDI Services Cindy Pope
Software engineer [email protected] 4
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Billing for 950 providers ~120,000 visits per month
Verification percentage: 75% $100M in charges, $27M in
payments/month 150,000 claims per month Clean claim rates of
95%
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Increased flexibility and efficiency when verifying and
updating insurance information in GE Healthcare. Ability to
customize results screens and file data eligibility data back into
the applications To receive more benefit information, and in a more
meaningful format. 8
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Centralized insurance verification team Grouped Eligibility
Request Definition (GERD) Real Time Requests On demand Ability to
request and verify eligibility on primary, secondary and tertiary
insurance. Automated Filing of Patient Insurance Data and Outcome
Customer defined needs review criteria enables work-by- exceptions
TES, AVM and ETM integrated workflows 10
UAB created fifteen payer GERDs. Appointment GERDs check
eligibility before the visit creates to ensure the eligibility
response information is correct upon visit. Visit GERDs verify
visits not created by an appointment. 13
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Result Screens can be customized by payer category. 14
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Eligibility was enhanced to allow the customer to create the
Needs Review reasons in an Enterprise Dictionary (48957). 18
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The new functionality allows the users to easily view the
specific NR Flag with the use of the NR Review Action Code. These
indicators serve as a guide to what steps the user needs to take.
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GE has a standard starter set for Eligibility sent and
Eligibility received task definitions 22
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We do not create tasks for real time verification Our initial
set up was for appointments and visits only The eligibility sent
was compared to the eligibility received to look for missing
responses Tasks were also created based on the eligibility status
looking for rejected or inactive verifications 23
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DBMS GERDS were created to give further flexibility. DBMS
Queries written with specific criteria enables sending requests on
a daily, weekly or monthly GERD. 28
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Queries allow incredible flexibility Medicaid appointments for
the 1-10 th day of the month are not verified until the first day
of the month as Medicaid eligibility is monthly, a query is used to
pull the appointments and a GERD is used to verify Alpha splits can
be used to match our credit letter cycles We use the queries to
meet individual team needs and associate a GERD to the query
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30 Example of charity care GERD query Some fields such as MRN,
name, SS# may be required to submit to your carrier
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Query for self pay patient to validate against Medicare.
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We have TES edits related to IMS questions populated by the
eligibility response. Results of inactive or rejected with TES
charges keyed to them are routed to the insurance verification
team. Blank verification IMS questions create a separate TES edit
which is routed to a IT analyst workfile. These edit results are
used in a query and verified via a GERD. A D19 field is used to
indicate which FSCs are included in the GE Ecommerce Eligibility
process and only those FSCs are included in the edit. 32
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With the GERDs we had a need to create tasks for active results
in specific scenarios, anything but active in some, and based on
the status and needs review flag results in others. The analysts
were monitoring the no response results through the GERDs not
through the ETM views 37
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We were creating many tasks which either remained unused or
required an agent to resolve or resolving tasks needed in our new
workflow Our new design created the tasks based on the specific
needs of the GERD 38
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49 GERD name and NR Reason columns
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An alert exists if the visit eligibility fields are blank
Previously we had alerts for rejected and inactive, these are now
replaced by the eligibility tasks The pre-arrival team works these
alerts from ETM 50
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Questions?
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