JLN Process - Eligibility inquiry by beneficiary

Process Group

Beneficiary Management

Objective

Provide Indication of whether beneficiary is eligible for health insurance coverage and details on specific services covered by plan benefits

Input

• Beneficiary identifier

• Benefits class

• Benefit plan

• Date of inquiry

• Demographic criteria

Output

• Time-based eligibility status

• Benefit cap

• Benefit Plan

• Status of co-pays/co-insurance

• Beneficiary accumulators

Measurable Outcomes

Beneficiary receives information about services covered by benefits plan, indication of whether benefits cap has been reached and totals for payment/co-payments made to date (beneficiary accumulators)

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf