O-11-602 Monthly Eligibility Verification
RESPONSIBLE POSITION: Elig/Auth Coordinator
PURPOSE: The first of every month, payer eligibility is verified for all clients enrolled in and actively billing a Medicare or Medicaid product for the purpose of identifying any changes in clients’ payers. This process gives overall direction on the steps needed to complete this task, focused on the steps needed at the branch level.
PROCESS: The task of verifying eligibility is split according to payer type between the Branch Authorization Specialists and the Account Managers in the Billing Department. See Appendix below for the details of task assignment for Account Managers.
Authorization Specialists are responsible to review monthly payer eligibility for the following payer types:
- Medicare-NGS
- Medicare Replacements (Medicare Advantage) – both PDGM & FFS
- Medica MSHO/PMAP
- Health Partners MSHO/PMAP
- Commercial
On the first of each month, tasks will generate in the Elig/Auth Coordinator HCHB workflow for clients with these active payers to be processed and cross-compared with reports sent from corporate staff. The different types of tasks generate from these payers as described in the table below:
| HCHB Workflow: Patient-Related Tasks | Event | Description |
|---|---|---|
| REVERIFY MEDICARE ELIGIBILITY | REVERIFY BENFITS MONTHLY | This task 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 the task "Reverify Medicare Eligibility" will resolve and disappear from workflow on its own. |
| REVERIFY PAYER SOURCE INFORMATION | REVERIFY BENEFITS MONTHLY | Generates for MDCR FFS, Medica MSHO/PMAP, HP MSHO/PMAP, and commercial payers. Additional review and follow-up needed. |
| REVIEW ON DEMAND ELGIBILITY ALERT | ON DEMAND ELIGIBILITY | Generates from Medicare-NGS or episodic Medicare Replacement payers and indicates that one or more alerts were found. Must be reviewed closely to identify any potential changes from the current payer. |
| REVIEW ON DEMAND ELIGIBILITY RESPONSE | ON DEMAND ELIGIBILITY | Generates when the payer is detected as Medicare-NGS. If the current payer is MDCR-NGS; no change is indicated and the task can be stage-completed. |
The Authorization Specialist will also receive the MEDICAID EVS Coordination Note in HCHB workflow under the Review Coordination Notes tab. This coordination note workflow is created by the Account Managers if they discover any follow-up needed as they complete their portion of monthly eligibility verification. Upon receiving this workflow, the branch is responsible to follow up on the information provided within the coordination note and resolve the indicated issue.
| HCHB Workflow: Review Coordination Notes | Description |
|---|---|
| MEDICAID EVS | Generates upon creation by the corporate account managers; contains information found during their review of clients' Medicaid eligibility. |
- On the first business day of the month, the Authorization Specialist will receive an email with three reports types generated from the Client Roster Report. If the branch is split according to teams, there may be three reports for each team or division. The reports will be run and sent according to three categories:
- Current Clients- MDCR Primary
- Current Clients - MDCR Secondary
- PENDING clients- All Payers
- Sort the patient-related tasks workflow in the following way (also include sorting by branch and team if needed according to your assignments):
By EVENT, then by TASK. This will help in identifying the EVS-related tasks and completing them in an efficient way.
Highlighted events and tasks are EVS-related.
- Use the reports described in step 1 to compare the client list to the patient-related tasks in HCHB workflow, verifying whether tasks generated for all specified clients.
- As the EVS tasks are processed, make note on the report that the task was completed. If there are clients on the report that do NOT have tasks, their eligibility must still be verified.
- After the entirety of EVS has been completed, reply back to the email with the updated report to confirm all eligibility has been processed. Please note on the report if task did not generate and eligibility was manually verified.
- It is likely that clients on the third report, for PENDING clients, will not have workflow generate as their workflow was probably already completed after Intake entered the referral. If this is the case, re-run and verify basic eligibility for active payers again to ensure no changes have taken place since the initial check prior to the first day of the month.
- If a change in payer source is identified, branch management should be notified to assist with identifying the necessary steps to complete the change. Here are some factors to take into account:
- Some payer changes, such as those involving any episodic payer, will require a Discharge visit and new Start of Care visit to be completed.
- A payer change that does not involve an episodic payer, change in client condition, or change in services rendered will not require a Discharge and Start of Care visit to complete the change.
- Timeliness of follow-up, especially regarding payer changes for episodic payers, will help prevent compliance issues and potential loss of revenue.
- If direction on a payer change is needed or any questions arise, email clinicalsystemssupport@adarahomehealth.com using this template below. Also include any relevant details or questions, and the corporate team will assist you.
Payer Change Template
Client’s name:
Current payer:
New payer:
Date new payer is effective:
If the client has a MDCR payer, does the client currently meet MDCR criteria?
APPENDIX
Account Managers (Corporate Billing Department) are responsible for:
Manually verifying eligibility for clients actively billing (primary or secondary) the following payer types:
- MN-DHS Medicaid
- Managed Medicaid (PMAP’s, excluding Medica MSHO/PMAP & Health Partners MSHO/PMAP
Information obtained by the Account Managers will be communicated to the branch via a Medicaid EVS Coordination Note, which routes to the Elig/Auth Coordinator workflow. When the information is received, the branch will follow up and take any action needed including contacting the appropriate payer/resource to resolve the issue.
Effective: 12.05.2025 | 🛠️ Revised: 12.05.2025 | ✅ Approved by: JFJ