HCHB Workflow Guide: Elig/Auth Coordinator
This guide includes an overview of all tasks and coordination notes routed to the ELIG/AUTH COORDINATOR responsible position in HCHB Workflow.
The workflow tasks are divided below according to these sections:
- Patient-Related Tasks: Eligibility
- Patient-Related Tasks: Authorization
- Review Coordination Notes
- Administrative Tasks
Patient-Related Tasks: Eligibility
| Task Name (arranged alphabetically) | Event(s) which trigger this task | Purpose |
|---|---|---|
| ENTER MEDICAID EFFECTIVE DATE | SOC/RECERT; CHANGE PAYOR |
Prompts you to check payer eligibility and benefits for a client’s upcoming episode of care (whether a SOC or Recert) or because of a change made in payor setup within HCHB. This eligibility task generates when the primary payer set up is Medicaid. |
| OBTAIN INSURANCE VERIFICATION | SOC/RECERT; CHANGE PAYOR | Prompts you to check payer eligibility and benefits for a client’s upcoming episode of care (whether a SOC or Recert) or because of a change made in payor setup within HCHB. |
| OBTAIN PRIVATE/SELF-PAY AUTHORIZATION | SOC/RECERT; CHANGE PAYOR | This is an eligibility task which generates either for a client's upcoming episode of care (whether a SOC or Recert) or because of a change in payor made within HCHB. This task prompts you to check for all possible payers (including MDCR and Medicaid) to see if there are any alternatives to private pay. If none are found or if we cannot bill the insurances they do have (for example, if the client has MDCR but doesn’t meet MDCR criteria), private pay must be billed if the client consents to continue with services, signing a service agreement. Connect with management for direction in cases that a client has no billable insurances. |
| REVERIFY MEDICARE ELIGIBILITY | REVERIFY BENFITS MONTHLY | This task generates as part of the monthly EVS process. It is essentially a placeholder task and prompts the user to send a 270 request if not already sent. When the 271 response is received back, the task "Review On Demand Eligibility Alert" or "Review On Demand Eligibility Response" will generate and "Reverify Medicare Eligibility" will resolve and disappear from workflow on its own. |
| REVERIFY PAYER SOURCE INFORMATION | REVERIFY BENEFITS MONTHLY | This task generates as part of the monthly EVS process. Verify the client’s eligibility for the current active payers which are set up to bill (primary, secondary, tertiary). You do not need to verify active alternative (informational only) payers unless the current payer(s) has a change indicated. |
| REVIEW ELIGIBILITY ALERT | SOC/RECERT; CHANGE PAYOR | Prompts you to check payer eligibility and benefits for a client’s upcoming episode of care (whether a SOC or Recert) or because of a change made in payor setup within HCHB. This specific task generates if the automated eligibility check (271) for Medicare has flagged one or more alerts, which will each need to be reviewed and addressed. |
| REVIEW ELGIBILITY RESPONSE | SOC/RECERT; CHANGE PAYOR | Prompts you to check payer eligibility and benefits for a client’s upcoming episode of care (whether a SOC or Recert) or because of a change made in payor setup within HCHB. This specific task generates if the automated eligibility check (271) for Medicare encounters no alerts, meaning that as long as the client meets MDCR criteria, the payer to be billed as primary would be MDCR-NGS. |
| REVIEW ON DEMAND ELIGIBILITY ALERT | ON DEMAND ELIGIBILITY | This generates because a 270 has been sent through HCHB, either via “Patient Actions” by an office user or as prompted by MDCR EVS. Eligibility must be verified. |
| REVIEW ON DEMAND ELIGIBILITY RESPONSE | ON DEMAND ELIGIBILITY | This generates because a 270 has been sent through HCHB, either via “Patient Actions” by an office user or as prompted by MDCR EVS. Eligibility must be verified. |
| VERIFY MEDICARE ELGIBILITY | SOC/RECERT; CHANGE PAYOR | Prompts you to check payer eligibility and benefits for a client’s upcoming episode of care (whether a SOC or Recert) or because of a change made in payor setup within HCHB. |
| VERIFY MSP ELIGIBILITY | MSP | A Medicare payer is set up as secondary and its eligibility needs to be verified. Verify eligibility and benefits for the secondary payer. This task should generate concurrent with an eligibility task for the client’s primary payer. |
Patient-Related Tasks: Authorization
| Task Name (arranged alphabetically) | Event(s) which trigger this task | Purpose |
|---|---|---|
| DETERMINE IF REAUTHORIZATION IS NEEDED FOR NEW ORDER | NEW PHYSICIAN ORDER; ORDER FOR ROC VISIT; RESUMPTION OF CARE |
A new physician order has been entered. This task prompts you to determine whether new and/or additional auth is required for increased visits or an added skill. |
| OBTAIN ADDITIONAL AUTHORIZATION | SOC/RECERT | The 485 (plan of care) from the SOC or Recert visit has been synced back to the office. This task prompts you to determine whether new or additional auth is required for the skills and number of visits ordered. |
| OBTAIN INITIAL AUTHORIZATION | SOC/RECERT; CHANGE PAYER |
Authorization must be added into the client’s chart. If actual auth has been obtained already, it can be entered as actual auth. If no auth is required, dummy auth (99 visits per skill) must be entered. If auth has been requested but not received, enter a pending auth for a timeframe of two weeks and enough visits to last during those two weeks (typically 2-4 visits per skill). |
| OBTAIN REAUTHORIZATION | REAUTHORIZATION | The end date of an authorization within an episode is approaching; new auth may be required. Review authorization and request additional auth if needed. If an auth request is made, enter a new pending auth. |
| REVIEW PRN VISIT DOCUMENTATION | PRN/UNPLANNED VISIT | A PRN (as needed) visit has been completed. This task prompts you to review the auth we currently have to see if it is sufficient for this additional visit. If not, auth will need to be obtained. Do not stage-complete the task until auth has been obtained or a pending authorization has been entered. |
| UPDATE PENDING AUTH WITH ACTUAL AUTH INFO | PENDING AUTHORIZATION | A pending authorization has been entered in a client’s episode. Actual auth must be obtained. Follow up to obtain additional auth. Pending auth should not be active longer than 2 weeks without receiving the actual auth. Do not extend the pending auth dates beyond 2 weeks unless you have obtained approval via a case-specific discussion with the Business Manager or Area Manager. |
Review Coordination Notes
| Note Type | Purpose |
|---|---|
| MEDICAID EVS ALERT | This generates at time of monthly EVS when an account biller (corporate biller) adds this type of coordination note to the client’s chart because of something they discovered when processing Medicaid EVS. Follow up as prompted by the notes within the note. |
Administrative Tasks
| Task Name | Purpose |
|---|---|
| PROBLEM BILLING- REVIEW/UPDATE PROBLEM BILLING | Complete this task when you have followed up (by phone call/voicemail/email) on every item within problem billing within the last 7 dates. Problem billing must be updated at least every 7 days but whenver possible should be addressed more often (for example, 2-3 times a week). |
Effective: 12.05.2025 | 🛠️ Revised: 12.05.2025 | ✅ Approved by: JFJ