Eligibility Checks: A walk through

Eligibility checks should be carried out regularl, preferably in a structured manner with predefined dates. One way could be to carry out checks 3 time a month, on the 1st day, the 15th day and the last day of every Month.

Here are two different examples of how eligibility checks can be carried out

1st Way

1. Log on to the Smart App

2. Click on New Era Rehabilitation Center icon

3. Click on the Print icon

4. Click on Patient ----- List of Active Patient ---- Alphabetical list by carrier (You’d see a full list)

** Ensure the run date is correct

** Put in the carrier & program

5. Click on ‘Generate Report’ (The report pops up)

6. Click on Save --- Export --- New Era--- EDI File --- Change the file type from pdf to csv --- Save in the Eligibility Folder (date first, Carrier). Close the page

7. Open New Era EDI --- Look for Eligibility

8. Copy the file & paste it on your desktop.
9. You can then open the file, we search for the eligibility of a client with his/her Client ID & Date of Birth on the relevant platform (the platform is dependent on the clients’ carrier). Once you put in the details, Click on search and check the ‘Response Text’ – A message stating whether he/she is eligible or ineligible.

10. Then input the information on the spreadsheet.

11. Once you identify the ineligible Clients, you’d use the format already provided to send the information/report to the appropriate officials/staff.

2nd Way

1. Log on to the Smart App
2. Click on New Era Rehabilitation Center icon
3. Click on the dollar sign ---- ‘Third Party Billing’ ---- Eligibility

4. Ensure the ‘from & thru dates’ reflect the present date. It won’t let you go back
5. Don’t change the carrier as long as it is BR Daily Medicaid Methadone – Not Active.
6. Click on Generate Report (The file name for Eligibility is 270 & the file we’d receive is called 271)

• You’d see a pop-up that the file has been generated
7. Go to New Era EDI on Smart, Click on it, search for Form 270, copy & paste the latest file on your desktop.
8. Upload the file on CTDSS, Transaction type - ‘HIPAA (x12 or NCPDP)’
9. Within a duration of 15 mins to a day, you’d have a response. To check the response – Go to Trade Files on CTDSS, download, Check ‘Eligibility Response’, download the file & save in EDI.

10. Click on Process 271 ---- Go to the file you saved in EDI & click on it. You’d see the document. Save in EDI-OSH – Eligibilty
11. Then go through the Eligibility details & identify the clients whose coverage have expired.
12. Note them down & send them to the appropriate officials.

Note: If you want to check few clients’ eligibility, you’d go to their various insurance sites/availity to check. This differs from our regular prescheduled eligibility check described above.