User Quick Guide Insurance Eligibility Demographic Updates. Contents. Document conventions

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1 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 Mapping for Subscriber Relation Fields Button update Button cancel Button ignore History Log and Audit Trail Tabular Report Upcoming Enhancement Document conventions Icon Note: Important: Description 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

2 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

3 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

4 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 popup: 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.'

5 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

6 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.

7 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.

8 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

9 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.

10 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.

11 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.

12 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 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

13 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 Spouse Self Child Employee Unknown Organ Donor Cadaver Donor Life Partner Other Relationship Mapped Eligibility Data for Comparison Spouse Self Parent Employer Other Other Other Life Partner 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.

14 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.

15 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.

16 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?

17 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 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.

18 Fig: Patient Registration History Fig: Patient Insurance History on click of button history.

19 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. 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.

20 Fig: Eligibility Report for patients on schedule Upcoming Enhancement: Efforts are being made to make the 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