How to Run the Report

Eligibility verification (s) are requests sent to Zirmed to verify a patient’s eligibility for one month.   Every patient’s eligibility is either approved or denied on a calendar month basis, by the payer.   It is important that eligibility is verified monthly, as beneficiaries may lose benefits or change insurance.  This ALL affects billing!

Patients that will be excluded from the report are: 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. 

Important:  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 the Eligibility Verification file:

This step creates the electronic file to send to Zirmed.  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, BUT no future dates are allowed.  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 payers in the left panel.
• Based on that selection, the proper information will be displayed in the first 3 checkboxes on the right side of the screen.   
• Check "Include Referred but Not Admitted", as needed. 
  
• Check "Create in e Solutions MVP format," if needed.
• Click the Create Eligibility File button.  The file transmission has been created.
• Click Print Patients in Eligibility Batch to print the transmission sheet.
• 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 - to Zirmed:

• Go to Billing > HIPAA Transactions > Transmit to Zirmed. 
•  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 Zirmed mail box, which will hold any files sent by Zirmed.
• From the top, left of the screen click the Eligibility bullet to view the file (s) 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 the file has not been sent to Zirmed. 
• 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 Zirmed.  You will want to come back to this screen later before you can proceed to the next step.

To Receive Zirmed'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 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 Zirmed Mailbox, search for a file size 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 Zirmed 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 the eligibility patient data.   Come back to this screen frequently to check for their response file, which will be a much larger file.
  

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.
• There are several print options.  You can preview each option, to determine the report version (s) you would prefer to print.   
• Click the Print Eligibility Verification button, to print the version of your choice.

How to Read the Report:

All:

Will print all report options.

Eligibility 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.