How to Run the Report

Eligibility verification are requests sent to NC Tracks to verify a patient’s eligibility for one month. Every patient’s eligibility is either approved or denied on a calendar month basis. It is pertinent that eligibility is verified monthly, as beneficiaries lose benefits or change insurance. This ALL affects billing.

Patients that will be excluded from the report are: patients without a Medicaid payer with Medicaid ID on the referral, patients without a sex entered on the referral, patients with a discharge date before the From date on the report, status of cancelled or Referred, not admitted - unless the checkbox "Include Referred but Not Admitted" is checked. 

We recommend using the following reports before creating the eligibility.  The reports will help verify that all required patient information is complete.  From Barnestorm Office click on Reports > Audit, use reports 07.01 and 07.02.

To Create Medicaid Eligibility Verifications file:

This step creates the electronic file to send to NC Tracks.  You are also able to print the report of patients that will be sent for review. 

• Go to Billing > Other > Create Eligibility Verifications   
• The Eligibility dates field defaults to the current month, but any previous month can also be created.  The From and Thru dates will pick up any active patient during that time frame. Patients discharged prior to the From date will be excluded.  Patients admitted after the Thru date will be excluded. 
• Click on one of the Medicaid payers in the left panel.
• Make your selections in the right panel.  Only one NPI can be used at a time. Check all of the "Include all payers with..." to pick up all other payers with the same NPI shown in the right side of this screen.   
• Check "Include Referred but Not Admitted", as needed. 
  
• PCS Agency: Check "Select All PCS" to ignore the NPI selected and pick up all PCS patients.
• Click the Create button.
• Print Patients in Eligibility Batch report.
• Close the report and then click anywhere on the list to return to the report options. 
• Repeat these steps for any other NPI or separate payers you need to generate a report for. 
  

To Send the Eligibility Transmission - file type 270:

This step transmits the electronic file to NC Tracks.

• Go to Billing > HIPAA Transactions > Transmit to NC Medicaid. 
•  The left side of the screen are the local files from your agency.  This is where the eligibility files are located that you have just created.
• The right side of the screen is your agency NC Tracks mailbox.  The files located here are controlled by NC Tracks. 
• From the top, left of the screen click the Eligibility or All Files bullet to view the files you need to send.
• There is a limited of 99 per file, so there may be more than one created, and they will all need to be sent.
•  The eligibility file(s) on the left side will have the type 270.  They should have a red arrow pointing to the right side of the screen - meaning it still needs sent to NC Tracks. 
• Select the file(s) on the left side, then click the Send button that appears in the middle. 
• At this point it can take several minutes up to a couple of hours before you receive a response back from NC Tracks.  You will want to come back to this screen later before you can proceed to the next step.
  

To Receive Medicaid’s Response:

This step will receive a response file back to confirm that they have received the file without any issues.  

• Continue from the Billing > HIPAA Transactions > Transmit to NC Medicaid tab.
• From the top, left of the screen click the Eligibility or All Files bullet to pull up the list of eligibility files.  Your 270 files should show up with a red arrow pointing up and a black background. 
• From the right side, within your NC Tracks Mailbox, search for a small file size (ex: 299) that has a date/time after you transmitted the 270 file above. Select it and then click on Receive.
• If that file matches up to your eligibility file, then the red arrow pointing up with a black background will change to a green checkmark. This means NC Tracks has received your file and will process the verification. 
• At this point it can take several hours before they will send back the actual verification report with patient data. 
  

To Print the Eligibility Verification - file type 271:

• From the Billing tab click on Other > Print Eligibility Verifications.
• Select the eligibility file you wish to print.  If someone else created the created the file to send, then you will need to delete the four-digit employee number in order for the file to show up.
• Select the option for All, Problems Only or Carolina Access Only, Information on each report follows. 
• PCS Agency: Print MCO Patient's report to determine which patients will need payers updated. 
• Click on Print.

How to Read the Report

All:

Will print all three options; Problems Only, Carolina Access Only.

Problems Only:

• Prog = This will be blank for the problem only patients.
• St = Status of the patient.
• Message = Shows reason (that goes with the status) why patient is on the problem list.
• 72 Invalid/Missing Subscriber/Insured ID means that the Medicaid HIC# was not found, or the name or birth date does not match the records.

        ** Inactive means that patient does not have Medicaid for the selected month of the report.

        ** Pvt Ins will let you know if the patient also has a private insurance policy.  Nothing else needs done unless the patient is being billed for skilled services, which may require a denial from the insurance first. 

Carolina Access Only:

• Prog = The first three digits are the Medicaid program code.  The fourth digit helps to indicate the status within that program.  See page 2-5 of the attached link. 
• St = Status of the patient. 

        OK if the eligibility status is OK

        MQ Medicare Premium Only = Medicaid will not pay claims, they only pay the Medicare Part B insurance premium.

        DE Deductible = This patient must meet a monthly deductible before Medicaid begins paying claims.

        EM ER Only = Medicaid pays for Emergency Room only.

        HC Health Choice = This patient is enrolled in Health Choice - children under 21 - and must be billed to the Health Choice provider.

• Phone Number = Phone number of the provider linked to the Carolina Access Provider.
• Carolina Access Provider = Name of Carolina Access Provider.
• Carolina Access Provider on file for =

        Will give the date of the month for eligibility.

        Including the Carolina Access Provider number.

• Second line under Carolina Access Provider =

              Will show the name of the Carolina Access Provider.

        ****MISSING**** means that no CA# was assigned for that month.

        ****MISSING**** Updated to means that the CA# was missing in referral but the description that came back in the EDI file is an exact match for one of the descriptions in the cross-reference file, Billing > Other > Carolina Access to NPI CrossReference, so the referral screen was updated with the matching CA#.

       If the top and bottom line have slightly different names for Carolina Access Provider = The top line is what came back in the EDI file; the second line is what the CA# cross-reference has, Billing > Other > Carolina Access to NPI CrossReference. 

Medicare Missing D9 - NC Only:

This report checks to see if the patient has Medicare.  If so, it will check to see if the patient has the condition code D9 setup in the Referral > Payer > Extra Billing Info screen. 

If the patient has Medicare but is not homebound, then you have to bill Medicaid and use the D9 condition code on the claim to indicate that Medicare is not the primary payer for that service. 

If you admit a homebound patient but only confirmed the Medicaid, and didn’t know about Medicare, then you will need to switch the payers, from Referral > Payer, to be Medicare standard.  

EDS does not use the same patient information database to verify eligibility that they use to pay claims.  That's why claims for a patient can be paid, and the eligibility returns a response of Patient Unknown.  If the spelling of the first name is different, if the date of birth doesn't match what's in the eligibility system, these can cause a Patient Unknown response.  

Medicaid eligibility only uses the above processes. 

NOTE:  The Check Eligibility tab option in the Referral screen is only for Zirmed (Medicare).

Dates of Service in Future: 

You’ll need to recreate the verification. The original eligibility that was created had a thru date past the current date. Use the default dates on the screen when creating verification for the current month. Example, if creating it on the third of the month it should look like: From 08/01/2009 – Thru 08/03/2009.