Checking a client's coverage

What it is. A coverage check sends the client's member ID, date of birth and payer to a clearinghouse, which asks the payer and brings back what the payer reports: whether coverage is active on that day, the plan's name and dates, and the copay, coinsurance, deductible and limit lines the payer chose to return. A coverage check returns what the payer reports on that day. It is not a promise of payment, and nothing is billed from here; claims are not sent from ExpressAgain.

Where it is. In your agency's workspace: Billing, the Eligibility tab, lists every client with the newest check and opens one client's panel; a client's own page, Documents & billing, has a Coverage block; and on Client intake, the in-home intake's Payer forms step shows Coverage once a payer other than private pay is chosen. Billing and the client's billing tab are for your administrators and your office (the same people who see money); the intake step is for anyone who may open Client intake.

Not connected. Until ExpressAgain connects a clearinghouse for this deployment, the button reads Eligibility checks: not connected, with a line saying who switches it on. Nothing is made up: on the live site a check never shows a sample answer. Your agency also needs its NPI on file (Setup, Send your agency verification, or the billing NPI in your organization's settings); without one the panel says so and the check waits.

Running a check. Tap Check eligibility. The form carries the client's first and last name, the member ID (from the family's insurance fields in Billing & pay, or the policy number on the intake payer step), the date of birth, the payer ID from the clearinghouse's payer list (keep its leading zeros), the payer's name and the service type: the general health benefit plan check, home health care or hospice. Run the check sends it; the answer usually comes back in seconds.

The result card. Active, Inactive, Unknown or Could not check at the top; then the plan name, when it was checked and by whom, the payer, the plan dates, the plan type, and the copay, coinsurance and deductible the payer returned. What the payer returned opens the full list of benefit lines, each with its amount or percent, network, coverage level, service and time period, as the payer wrote them. Unknown means the payer answered without a clear active or inactive, usually a rejected member ID or date of birth; the payer's message is under the card. Could not check means the clearinghouse did not answer; try again in a minute.

Re-check and the history. Re-check runs the last inputs again. History of checks folds under the card with every check, newest first, its status, who ran it or that it was automatic, and which clearinghouse answered. The vendor's whole answer is kept sealed at rest; the card shows the summary.

Automatic re-checks. Once a clearinghouse is connected and a client has been checked by hand at least once, ExpressAgain re-checks that client on its own: three days before each authorization's first day (unless a check is less than a week old), and every thirty days for a client billed to Medicaid waiver or Medicaid managed care. The sweep runs on the daily schedule, uses the last check's inputs, and never runs on sample answers. A client who was never checked by hand is not re-checked.

Which clearinghouse. The built adapter is for Stedi, from its public documentation; it switches on when ExpressAgain sets its key. A second clearinghouse can be added behind the same screen. Sending claims (837P) and reading remittances (835) are the next phases and are not built yet.