user quick guide insurance eligibility demographic …...hyperlink zins elig details [ and zins elig...

Copyright 2012, Bizmatics, Inc. 4010 Moorpark Avenue, Suite 222, San Jose, CA 95117

User Quick Guide Insurance Eligibility Demographic Updates

Contents Document conventions............................................................................................................................ 1

Intended audiences ................................................................................................................................. 1

Introduction ............................................................................................... Error! Bookmark not defined.

Pre-requisite ........................................................................................................................................... 3

Authorizing user role ............................................................................................................................... 4

Screen accessibility .................................................................................................................................. 5

Functionality of feature ........................................................................................................................... 7

Different Senarios ................................................................................................................................... 8

Fields Supported for the Comparison..................................................................................................... 12

Mapping for Subscriber Relation Fields .................................................................................................. 13

Button ‘update’ .................................................................................................................................... 14

Button ‘cancel’ ...................................................................................................................................... 16

Button ‘ignore’ ...................................................................................................................................... 16

History Log and Audit Trail..................................................................................................................... 17

Tabular Report ...................................................................................................................................... 19

Upcoming Enhancement ....................................................................................................................... 20

Document conventions Icon Description

Note: To create awareness about the fact.

To emphasize about aspects which are critically important and should be adhered to instruction.

Intended audiences Intended audiences for this document are:

Front-end Implementers

Technical support

QA department

Important:



Training Department

Marketing and Sales Departments

Introduction

This document provides information on how to use the ‘Demographic Updates’ functionality

using Insurance Eligibility data. This document will also help us to understand how mismatch

between Insurance Eligibility info and PrognoCIS info is detected and updated in PrognoCIS.

This feature is an extension to Insurance Eligibility functionality and is applicable for clinics

which have Insurance Eligibility Feature Turned ON.

Using Patient Demographic information received from Eligibility, now it will be possible to

populate or update the equivalent fields in PrognoCIS.

When Insurance Eligibility is fetched, the Patient Demographics information from Eligibility file

is compared with the PrognoCIS information. In case mismatch is observed then it is highlighted

in icon on the Patient Insurance Screen , Insurance Eligibility ‘details’ button

on Patient Insurance screen and hyperlink on Tabular Report. In addition, Patient and

Subscriber Information will also be available for updates, but Provider and Insurance Details will

not be available for updates. Further, user will decide whether they wish to update each

PrognoCIS field with Eligibility Information based on whether the user has the rights to do the

updates (‘No Access’ Role). The updated information can be tracked in Patient Demographics

Update History, Patient Insurance History and in Audit trail, along with the user details, like who

updated it and when.

Currently, there are 4 clearing houses supporting Insurance Eligibility Feature. This new feature

of Demographic Updates based on Eligibility will be supported for all these clearing houses.

Gateway

Navicure

Assurtus

Inmediata



Pre-Requisites for using Demographic Updates Feature in PrognoCIS The Demographic Updates feature will be available by default for all clients who have Insurance

Eligibility import already turned ON. The property ‘inseligibility.demographic.update’ will be ON

by default. If a user doesn’t want this feature to be turned ON, they can request Tech Support

to turn this property OFF. If the property is ON, an Icon of Demographic Updates will be

displayed on Patient Insurance screen next to Eligibility ‘Check’ and ‘Details’ button and also

inside ‘Details’ button, provided the User has appropriate Role ‘EligibilityDemographicsUpdate’

assigned from User Role screen. Further, when the property is turned OFF, then the

Demographics Updates icon will not be displayed on Patient Insurance and Eligibility Details

screens.

Note: Latest Eligibility fetched for a patient after this feature is added qualifies for this

Demographic Comparison and mismatch Updates. If latest eligibility for a patient was fetched

before this feature upgrade, the Demographic Updates icon will be shown disabled.

Note 2: If the latest Eligibility record fetched for a patient is an error, the Demographic Updates

icon will be shown disabled.

Fig: Two New Properties governing the Feature



Another new property ‘ins.eligibility.patient.info.comparison.fields’ has been introduced. This

property accepts Comma separated numeric values for 32 fields defined in the program. If

comparison of Eligibility and corresponding PrognoCIS Patient Demographics field has to be

done, then that field number has to be present in the comma separated list. The sequence of

these numbers doesn’t matter. When the property ‘EligibilityDemographicsUpdate’ is set to ‘Y’

and property ins.eligibility.patient.info.comparison.fields left blank, then by default the value of

the property is considered as all 32 fields comma separated i.e.

1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32.

The field name for each number is given in a table below.

After V3B3, this property will have a list to choose these options from instead of a Text Box

which accepts comma separated numbers. This List accepts multiple values in any sequence. Its

called MVALSET data type.

Authorizing User Role for updating Demographics:

Settings>Configuration>User Roles: EligibilityDemographicsUpdate- this is a ‘No Access’ Role

introduced.

By default, the Demographic Updates icon will be viewed by all PrognoCIS Users if the feature is

turned ‘On’ and there is a mismatch, but, not all users will be able to see the buttons ‘update’

and ‘ignore’ enabled from this Demographic Updates Icon. Only those users, who have the User

Role checkbox for new role EligibilityDemographicsUpdate checked, will be able to update the

Demographics or ignore mismatch. By default only Admin user will have this role assigned. The

Clinic Manager should appropriately assign it for Clinic employees.

For Users with above Role Assigned following will be observed on Demographic Updates pop-

up:

• The check boxes with mismatch rows will show enabled.

• Button ‘update’ will get enabled when first check box is checked.

• Buttons ‘ignore’ and ‘cancel’ buttons will be always enabled.

For users with above Role not Assigned:

• The check boxes with mismatch will be enabled.

• Even after check boxes are checked, ‘update’ and ‘ignore’ buttons will remain disabled.

• On clicking any mismatch check box following message will be displayed - 'Sorry! You do not

have Role “EligibilityDemographicsUpdate" assigned.'



• Button ‘cancel’ will be always enabled.

4 places from where Demographic Updates screen is accessible:

The icon ‘Patient Demographics and Eligibility Mismatch and Updates’ pop-up will be made

available from three options:

A new icon on Patient > Insurance Pop-Up

Fig: Showing Demographic Updates Icon on Insurance Pop-Up (Tooltip shown)

A new icon on Patient Insurance > Eligibility: “Details” - Pop-up



Fig: Insurance Eligibility Details pop-up with new icon for Demographic Updates

Hyperlink ‘Ins Elig Details’ and ‘Ins Elig Demo Updates’ on new Tabular Report

(TELIG304) named ‘Patient Eligibility Demographic Mismatch List’.

Fig: Showing Hyperlink on Tabular Report TELIG304

Hyperlink ‘Ins Elig Details’ and ‘Ins Elig Demo Updates’ on existing Tabular Report

(TELIG301) named ‘Eligibility Report for patients on schedule.



Functionality of feature ‘Demographic Updates using Insurance Eligibility’:

Insurance Eligibility Response can either be run at night using a scheduled process ‘Get

Insurance Eligibility for Scheduled Appts’. Else, the eligibility can be explicitly fetched using

button ‘check’ on Patient Insurance screen.

Now, after the Eligibility info is fetched, it will be compared with Patient Demographics info in

PrognoCIS and if there are any differences found then they will be available for mismatch

updates. Latest successful Eligibility info for a patient will be considered for comparison and

stored. Further, whenever any user comes to Patient Insurance or ‘details…’ pop-up, the

demographic updates icon will be shown enabled only if there is atleast one mismatch

found. On the contrary, if no mismatch found then the icon will remain disabled.

Fig: Demographic Updates Icon shown enabled when one or more fields have a mismatch

Clicking on the icon invokes a pop up displaying comparison of information.



Fig: Patient Fields on Demographic Updates pop-up

There are two tabs that are shown in the ‘Demographic Updates’ pop-up:

a. ‘Patient’

b. ‘Subscriber’

Patient Tab: Currently, there are 32 fields supported at max to be displayed on this pop-up.

When the pop-up is invoked by default the first tab ‘Patient’ will show selected and its details

will be displayed. Currently, there are 19 fields supported under ‘Patient’ tab including 5 fields

for Address. On screen only 14 fields can be seen as Address is shown in single row. If any



mismatch is found between data from Eligibility and from PrognoCIS, the check box present for

the row will get enabled.

There will not be any automatic updates in patient demographic information. Instead, it will be

an explicit user action. User will take explicit decision whether to update the data from

Eligibility if different into Patient Register and/or Pat-Insurance screen of PrognoCIS by explicitly

checking the mismatched fields checkboxes.

A ‘select all’ check box is present next to the column ‘Update In PrognoCIS’. User can check this

check box to select all the check boxes which are enabled easily. User can also check the

required check boxes manually where they want certain Demographics to be updated in

PrognoCIS. This ‘Select All’ checkbox will be enabled only when atleast one field on that page is

editable.



Fig: Patient Fields on Demographic Updates pop-up showing Select All checkbox enabled.

Subscriber Tab: The second tab is ‘Subscriber’. This tab currently supports 13 fields including 5

fields for Address but visible fields are only 9 because Address of Subscriber is shown in a single

row. Unfortunately very few fields are actually received while fetching Eligibility. The details

present under the Subscriber tab are coupled to the ‘Relation’ field in the patient tab. If the

check box ‘Relation’ is checked on the ‘Patient’ tab then following three fields in the

‘Subscriber’ tab i.e. ‘Subscriber First Name’, ‘Subscriber Last Name’ and ‘Subscriber DOB’ gets

automatically checked if there is a mismatch and are disabled. All other fields with Mismatch on

the Subscriber tab also show the checkbox checked but those checkboxes are enabled in case

the user wants to skip them from updates.



Fig: Subscriber Fields Enabled with Last and First Name checked and disabled.)

The Subscriber Tab will be shown Disabled in following situations:

1. When PrognoCIS Subscriber Relation and Eligibility Subscriber Relation both are ‘Self’. 2. When PrognoCIS Subscriber Relation is other than Self but Eligibility Subscriber is ‘Self’.

Fig: Subscriber Fields on Demographic Updates pop-up showing disabled

What this means is that when Eligibility info has Relation as Self, then Subscriber Tab will be

shown disabled. For changing Subscriber to Self, user will have to manually change the field

‘Relation’ from Patient Insurance Screen. Only then will the reference of Subscriber be removed

from program, else not.



List of Fields Supported for the Comparison including Patient and Subscriber tabs: The

number for each field is considered in the Comparison field.

1. Patient Last Name

2. Patient First Name

3. Policy Num/Subscriber ID

4. Pat DOB

5. Pat Gender

6. Pat SSN

7. Subscriber Relation

8. Pat Add Line1

9. Pat Add Line2

10. Pat City

11. Pat State Code

12. Pat Zip

13. Pat Res Tel

14. Pat Fax

15. Pat Email

16. Plan ID

17. Group No

18. Plan Start Date

19. Plan Expiry Date

20. Subscriber First Name

21. Subscriber Last Name

22. Subscriber DOB

23. Subscriber Gender

24. Subscriber SSN

25. Subscriber Address Line1

26. Subscriber Address Line2

27. Subscriber Address City

28. Subscriber Address State

29. Subscriber Address Zip

30. Subscriber Address TEL

31. Subscriber Address Fax

32. Subscriber Address Email



In the above mentioned fields, if any deviation is found in PrognoCIS info from fetched eligibility

response, then the patient will qualify for Demographics Updates.

Mapping for Subscriber Relation field:

A hardcoded Mapping Table is defined in PrognoCIS for mapping appropriate Subscriber

Relations from Eligibility with Relation defined in PrognoCIS. For Example - When Eligibility

value for Relation is sent as ‘Child’, the program interprets as ‘Parent’ and then compares it

with relation in PrognoCIS.

Eligibility Data Received Mapped Eligibility Data for

Comparison

Spouse Spouse

Self Self

Child Parent

Employee Employer

Unknown Other

Organ Donor Other

Cadaver Donor Other

Life Partner Life Partner

Other Relationship Other

For ex: If Relation comes from Eligibility as ‘Child’ and PrognoCIS has Relation set as ‘Parent’

then it will be considered as match, else a mismatch.

I.e Eligibility info sends Patient’s relation to Subscriber whereas PrognoCIS stores Subscriber’s

relation to Patient. That’s why conversion is needed.



Button ‘update’

Initially the button ‘update’ remains disabled but after checking any ‘Update In PrognoCIS’

check box, the button gets enabled. Clicking on the ‘update’ button initiates some validations

after which appropriate messages are displayed and check boxes get checked, unchecked or

disabled.

If any of the Subscriber details check box is checked but field ‘Relation’ on ‘Patient’ tab is

unchecked, then a validation message is displayed saying, ‘Please select Subscriber Relation

from Patient Tab.’

Note: This validation should take place only if ‘Relation’ check box is enabled for update.



Fig: Validation on checking Subscriber details checkbox when ‘Relation’ checkbox on ‘Patient’

tab is unchecked.

When none of the checkboxes on the ‘Patient’ tab are checked and users click the button

‘update’, a validation message saying ‘Please select atleast one Field to update’ is displayed.

Fig: Validation on the button ‘update’ when no checkbox checked.

The updates are available till the next ‘Eligibility’ is fetched for the same patient or until

Updates are done in PrognoCIS. Latest Eligibility of a patient will be considered for

Demographics comparison and updates. If the new Eligibility fetched does not have the updates

like last Eligibility mismatch or any other mismatch, then Demographic Updates icon will

become disabled.



Button ‘cancel’

If any check box is checked then clicking on the button ‘cancel’ will invoke a validation message saying

‘Are you sure you want to exit without updating changes in PrognoCIS?’ On clicking the ‘ok’ button the

pop-up get closed and parent screen is shown. On clicking the ‘cancel’ button, the validation message

pop-up gets closed and user remains on the same screen.

Fig: Validation on Button ‘cancel’

Button ‘ignore’

The button ‘ignore’ is used when user is sure he wants to ignore the fields even if there is mismatch

because they are ok with the data in PrognoCIS. On clicking the button ‘ignore’ a validation message

appears saying ‘By clicking button 'ignore' the Demographics Updates icon will be disabled till Eligibility

is fetched again and mismatch is found. Are you sure you want to proceed?’



Further, on clicking the ‘ok’ button to proceed, the validation pop up and Demographic Updates pop up

will get closed and the Demographics Updates icon will become disabled. Else, on clicking the button

‘cancel’ the validation pop up will get closed and user will remain on the same screen.

Fig: Validation on Button ‘ignore’

History Log and Audit Trail:

All the users actions related to Insurance Eligibility Demographic Updates will be logged in to

the audit trail under the ‘Menu’ Option – ‘Patient Insurance’. For both Patient and Patient

Insurance screen fields, the Menu option used to save in Audit Trail is the same. In addition, the

button ‘History’ on the ‘Patient Registration’ and ‘Patient Insurance’ screen also displays the

updates done through Insurance Eligibility Demographic Updates.



Fig: Patient Registration History

Fig: Patient Insurance History on click of button ‘history’.



Fig: Audit Trail Report

Tabular Report

A new tabular report named ‘Patient Eligibility Demographic Mismatch List’ Code TELIG 304

has been introduced along with this feature. The report gives a consolidated list of all current

patients who are flagged to have some mismatch in Patient and Subscriber Demographics in

PrognoCIS while comparing with Insurance Eligibility Demographic information fetched in

selected date range. By running this report user will also be able to access Insurance Eligibility

Details and Insurance Eligibility Demographic Updates. It will allow working on all patients with

mismatches from a single list.

Last Eligibility fetched Date is considered here. 1st Hyperlink for each patient is 'Insurance

Eligibility Details' which when clicked will open the Eligibility Details pop-up which will show

latest Eligibility Details fetched. The second hyperlink is 'Insurance Eligibility Demo Updates'.

By clicking this link, the Demographics Updates pop-up will open where the list of Patient and

Subscriber fields from PrognoCIS and Eligibility are shown for comparison. The users will be able

to update one or more mismatched fields by selecting the appropriate fields and clicking button

update. The update button will be disabled if a user doesn’t have appropriate user role

assigned. The patient goes away from the report if all mismatched fields are updated or ignore

button is clicked to ignore the mismatches.

Fig: Patient Eligibility Demographic Mismatch List

Same two columns 'Insurance Eligibility Details' and 'Insurance Eligibility Demo Updates' are

also added in tabular report ‘Eligibility Report for patients on schedule’ Code TELIG 301.



Fig: Eligibility Report for patients on schedule

Upcoming Enhancement: Efforts are being made to make the Insurance Eligibility Demographic Updates Feature more effective. During Patient Registration, if users are let to add basic minimum information required for fetching eligibility like Insurance and Subscriber ID, we can trigger automatic Eligibility fetching action and also do automatic Demographic fields comparison and update the blank fields. This way, users will not be required to add fields like Patient Address, SSN, Subscriber Details, Plan Details manually. Defining Patients will become very easy and quick.

Document Details

Created by: Meghna Chakravorty

Created date: March 14, 2016

Verified By: Malvika Tarnekar

Last updated: May 13th, 2016

Version Introduced In: V2B2.1 (Patch)

Document Version: DemographicUpdates_2016_V3B2.1

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