Value-Added Features

Pre-Processing

Below are a set of capabilities that enhance or augment the 270 request process prior to sending it to the clearinghouse.

Deduplication

Before dispatching your 270 transaction to the clearinghouse, this capability saves your organization transaction costs by querying past transactions you've submitted and returning their response. A transaction is considered a duplicate when key fields in the request have been previously submitted by the same customer to the same payer. The window of time for querying duplicate requests is within your control. We call this the "lookback" period.

If a duplicate transaction request is found, your new request will short-circuit the transaction workflow. The response returned will be an enhanced 271 response associated to the matching duplicate request.

Payer Aliasing

The Payer ID derived from an Electronic Health Record (EHR) or Health Information System (HIS) is the Payer naming convention that your organization uses to refer to that Payer. In most cases, it does not match the clearinghouse identifier for that Payer. Payer Aliasing provides a mapping to from EMR/HIS Payer ID to an Optum Payer ID so that you can continue submitting the ID as it relates to your system.

National Provider Identifier (NPI) Management

This feature provides the ability to automatically apply NPIs to your outgoing transaction request based on the information you provide in your request. You can define a default value for every transaction or more granular values based on the combination of Payer and Facility.
The mappings you choose to define are evaluated in a hierarchical order. Based on that order, the system will select the most specific mapping to use during transaction processing. In priority order, the hierarchy is as follows:

  1. Request matches on Customer, Payer, and Facility
  2. Request matches on Customer and Facility
  3. Request matches on Customer and Payer
  4. Request matches on Customer
  5. Fallback to supplied NPI value in the original request

Post-Processing

Below are a set of capabilities that enhance or augment the 271 response after to receiving a response from the clearinghouse.

Payer-Response Normalization

After clearinghouse processing, the Enhanced Eligibility API molds the 271 response into a developer-friendly JSON-based response by normalizing EDI segments into a named benefit field using Optum’s database of normalization rules.

Coverage Discovery

Below are a set of discovery "paths" that facilitate automated discovery of patient coverage when the conditions are met.

Medicare

The Medicare path evaluates demographic data to inform a patient's candidacy for Medicare discovery.

HMO

HMO discovery evaluates the 271 response for data that indicates enrollment with an HMO. The Enhanced Eligibility API will submit a transaction with the HMO payer to see if the patient is eligible.

Medicaid

The Medicaid path evaluates provided insurance coverage to inform a patient's candidacy for Medicaid discovery.

Commercial Payers

Optum works with the Customer to determine an appropriate list of commercial discovery Payers based on historical transaction volume and provider data.

Coverage Insight

Coverage Insight uses analytics-driven insurance verification software that integrates advanced discovery into this workflow. You can expect that this path will take between 24-72 hours to determine coverage.

Minimum Required Data

In order to successfully send requests to Coverage insight, the required fields below must be present on the incoming request. If any of the below requirements are missing, the transaction will be ignored.

  • Patient Account Number
  • Patient's First Name
  • Patient's Last Name
  • Date of Birth
  • SSN or Address

Previously Processed Encounter

If an encounter was previously processed (identified by the Patient Account Number), the request will be ignored by Coverage Insight. A new Patient Account Number (PAN) must be submitted on the request in order to have the transaction processed.

For more information about Coverage Insight, take a look at the following documentation: https://www.changehealthcare.com/revenue-cycle-management/financial-clearance/coverage-insight


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