When a patient seeks healthcare services from a healthcare provider, the provider may request information from a payer (e.g., insurance company) to determine if the patient is eligible to receive benefits for healthcare services; and if the patient is eligible, other benefit and eligibility information such as benefit amounts, co-insurance, co-pays, deductibles, exclusions, and limitations related to a specific procedure may be provided. The request for information may be sent as an eligibility request, for example, a 270 request or transaction. A payer may communicate eligibility benefit information associated with a subscriber or dependent in a response, for example, a 271 response or reply.
The eligibility request and response may be required to meet transaction processing standards. For example, eligibility transactions may be sent in an X12 syntax format and may be coded and structured according to standards established by the Secretary of Health and Human Services (HHS) as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As is known in the art, HIPAA includes provisions for administrative simplification and support electronic exchange of administrative and financial healthcare transactions primarily between healthcare providers and plans. As should be appreciated, embodiments may be utilized with other formats, structures, and syntaxes according to changes in healthcare laws. For example, a 270 eligibility request may be replaced by an eligibility request of another format and utilizing an alternate syntax. A 271 response may be replaced by an eligibility response of another format and utilizing an alternate syntax.
When insurance eligibility and benefit information is communicated in a 271 response, the information may be improperly documented or may be inconsistent with patient information in a healthcare provider's information system. Currently, to overcome improper documentation and inconsistent information, users may use cheat sheets or other types of manual instructions written for individuals to look at data elements and compare it to documentations. As can be appreciated, this can be very time-consuming and prone to error. The ability for users to identify the information he/she needs in order to properly execute the registration process and to collect any up front co-pays, etc., may be challenging. It is with respect to this and other considerations the present invention has been made.
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