Eligibility Verification
CareCLAIM from OmniSYS includes over 400 proprietary edits that ensure “clean claims” including checks for missing or invalid patient information. Excluding patient eligibility, the majority of claims that pass CareCLAIM’s edits are paid when first submitted to Medicare. One edit checks the format of the patient’s HICN (Cardholder ID) for proper length and mix of alphanumeric characters; however, this edit cannot identify when two digits are inadvertently reversed within an HICN. This is one example of “data entry” errors that result in Medicare denials.

Patient eligibility issues represent the primary reason for Medicare denials – over twenty percent (20%) of submitted claims are for ineligible patients or for patients with missing or invalid eligibility information. In fact, so-called “ineligible” patients usually are eligible but the patient information submitted is not sufficient to identify the patient through Medicare’s Common Working File.

Patient information needs to be correct before claims are submitted to Medicare.  Ideally, your pharmacy management system should match the Common Working File.  Other types of eligibility errors include patients enrolled in Medicare HMOs (as opposed to traditional Part B) and claims with dates-of-service that fall outside the patient’s Medicare Part B Effective/Termination dates.

Most Medicare claims will benefit from online eligibility edits that automatically check for eligibility on each Medicare claim you submit - at the same time other edits are performed.  CareCLAIM from OmniSYS includes eligibility verification with customized NCPDP messaging that drives the pharmacy to match the Common Working File at the point-of-sale. In addition, for limited situations when eligibility verification is not available online, a web-based tool informs the pharmacy when products are dispensed for: 1) ineligible patients; or, 2) eligible patients with missing or invalid information. For these scenarios, claims are placed on-hold indefinitely until the patient information is corrected by the pharmacy and all affected claims are reversed and resubmitted to CareCLAIM.