Medicare Eligibility - What it is and how it works (KB)

December 3rd, 2018

What is Medicare Eligibility?

Medicare Eligibility is a feature in Sammy used to verify if a patient is active with Medicare, if they have an HMO policy, a deductible and how much has been paid to date.

How does it work?

In system setup there is a button labeled "MCR Elig Preference". When you click this button you will see the configuration screen in which you can customize the Medicare eligibility feature to suit your needs.  This is stored in System Setup so it does not get changed by just anyone within the office.  When you change any of these settings a record is created so that the intentions of the user who changed them at that particular time are clear. There are four options to consider in this configuration screen, each are outlined below.

  1. "Let Me Select Which Medicare Claims Are Sent" - This choice does not send out any claim unless the patient has met the requirements for eligibility. However, if there is any payment posted in the section Paid on Form on the billing screen, that claim will go out, as this is the amount you would like to report to the insurance company that was paid toward the claim by the patient at the time of service. You may notice one or more of the following statuses listed under the "future date" column of the transmit screen: DEDHOLD, HOLDDED, HOLDCHK, SENDNOW and SEC2PAY.  However, if a date is entered in the "future date" column the claim will be sent on that date bypassing the Medicare eligibility feature.
    1. DEDHOLD - These are the claims that you have manually placed on your deductible watch list. 
    2. HOLDDED - These are the claims that are using the feature.  The patients have not met their deductible as per CMS and will not be released to the carrier.
    3. HOLDCHK - These are the claims using this feature but the eligibility has not yet been checked.  They will be sent in an eligibility batch with the first submission to Medicare each day.
    4. SENDNOW - These are the claims that you are overriding the eligibility system with.  This means that the claim will not be checked to see if there is an outstanding deductible and will be sent to the carrier with the next submission.
    5. SEC2PAY - These are claims that you are indication that the Secondary insurance will pick up the deductible and you would like to send this claim without it being checked.For more information on SEC2PAY please click here.
  2. Do Not Automatically Print Results: When a patient is not found in the Medicare system for any reason (invalid subscriber id, invalid date of birth, deceased, etc...), belongs to an HMO/MCO, has Medicare as a Secondary Payer - Sammy will print out the notification automatically.  If you do not want this notification to print automatically choose this option.
  3. Automatically Save Results In The Filing Cabinet:  This will save a copy of the eligibility results to the filing cabinet.  This will not work for SimpleSam clients as they do not have the filing cabinet.
  4. Don't Check Patient Appointments: If you do not use or do not have the appointment calendar and you do not want Sammy to check eligibility status of patients coming in, choose this option.
  5. Hold Claims for patients with QMB status: By default, if you have "Let Me Select Which Medicare Claims Are Sent" checked, the "Hold Claims for patients with QMB status" will automatically be set to on. If you do not have "Let Me Select Which Medicare Claims Are Sent" on, the "Hold Claims for patients with QMB status" will NOT be turned on. This means that your practice has decided which claims are to be held. Click here for more information regarding QMB.
  6. Check ALL Claims On Next Send: This is a one time option. When you check this, all claims and appointments that have not been checked in the last 5 days will be sent during the next Morning Index run. If a file was already sent for that day, those will not be included the following send. Additionally, if any claims have had a hold status with anything other than the standard eligibility options (blank will be included), they will not be sent for eligibility checking.

When you change any of these settings a record is created so that we all know what the intentions were at a particular time.