JLN Process - Eligibility inquiry by provider

Process Group

Beneficiary Management

Objective

Provide accurate and timely indication of whether presenting individual is eligible for health care coverage at this point in time at this location and if specific services to be rendered are covered by the individual’s benefits plan

Input

• Beneficiary identifier

• Provider identifier

• Benefits class

• Benefit plan

• Encounter date

• Beneficiary accumulator

• Demographic criteria

• Clinical criteria

Output

• Time-based eligibility status

• Benefit cap

• Pre- authorization

• Beneficiary accumulators

Task Set

• Identity verification

• Pre- authorization

Measurable Outcomes

• Provider understands the extent to which services rendered are covered by the individual’s health care plan

• Individual is informaed of the extent to which services are covered under their health care plan

Task Flow Diagram

Open

Open

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf