Purpose
Eligibility Manager® lets you easily update your data management system with new health plan data. We want this process to be as quick and accurate as possible, with a minimum of manual intervention. Eligibility Manager inputs a full or partial list of member data from a health plan and creates a list of membership changes.
The key features of Eligibility Manager are its ease of use, its structure that was designed to allow implementation of custom logic to handle data in varying formats from different health plans, and its simple but powerful auditing tools to guarantee data is clean before updating your system.
Overview
Once Eligibility Manager has been set up, the following basic steps are used:
- Import current data for one health plan
- Import health plan data
- Manage lookup tables and other data issues
- Compare current and health plan data and generate change records
- Review and edit change records
- Export change records for uploading
These processes are described in more detail below.
Setup
You can configure any number of medical groups from any databases. When processing data, you simply select the appropriate group.
Each health plan is configured separately. Some configuration is available at the user level, including data file field mappings.
Eligibility Manager has been set up to make it easy for DataWing Software® to supply custom code for each health plan. We have a very rich library of necessary logic for all major plans.
Detailed specifications of custom logic for each health plan can be displayed within Eligibility Manager.
Importing Current Data
You import eligibility data for one health plan by selecting the plan from the list of available plans.
Member data, eligibility data, and PCP data are imported.
PCP Term Dates in are copied into Eligibility Manager. These are used to verify that members are not assigned to these PCPs.
Importing Health Plan Data
You import health plan by selecting the plan from the list of available plans, and then selecting a file. Standard and custom code for the health plan will be executed on the selected file.
Multiple data files can be selected and Eligibility Manager will combine their data.
Custom settings for each health plan make the following processes possible:
- Read the member records from the data file.
- Translate health plan PCP IDs and other codes, including language, ethnicity, etc.
- Generate any required plan codes, option codes, etc. User-editable tables can be supplied to make these criteria flexible.
- Effective dates may be manipulated to reflect contract dates or other needs.
Eligibility Manager Data Management
New codes, (for example PCPs, employer groups and options codes) are displayed so that you can add them to Eligibility Manager and your system.
You can display or print a list of Missing Members – active in your system, but missing from the health plan data. (These are members you are paying claims and capitation for, but the health plan is not paying you).
Health plans often send effective dates for members with respect to the health plan, not your effective dates. Logic can be applied to ignore the health plan's effective date if a PCP or Option has not changed.
Integration with DataTug™
With Eligibility Manager and DataTug, there is no need to painstakingly verify current eligibility data. When Eligibility Manager provides a list of Missing Members, or if you select a member you would like to verify, Eligibility Manager will package up the list of members, call DataTug to retrieve the current medical group's information for those members from the health plans' web sites, and retrieve that information within Eligibility Manager.
Comparison
A single click generates a list of differences between the health plan data and your current data.
The list of fields examined for generating change records is user-configurable.
A change record will also be generated if a member is assigned a PCP who has a Closed Status in the PCP Lookup table.
Review Changes
The Review screen allows you to simply see all the changes in the eligibility data. Easy but powerful tools allow you to audit this data and make changes.
Change records are all displayed on one screen, in a tabular format. (Click Here to view a sample of the Review Changes screen.)
For each record, all health plan data is listed.
Current data is only shown where it differs from the health plan data.
All health plan data can be edited.
Simple Filter and Replace tools make it easy to make bulk corrections when necessary. Record can be selected based on compound criteria.
A powerful Audit tool allows you to create any number of validation rules. These rules are then applied to all change records. When a record violates one or more rules, a code is displayed showing you the exceptions.
Export
Click Export to export the resulting change records.
One file is created with all the changes.
Separate files are created with just the Adds, Terms, and Changes.
The User Interface
All screens have easy-to-use menus and toolbars.
All data lists can be sorted, printed, and exported.
You can specify your favorite text editor to be used for viewing data files.
Other Features
Detailed documentation is supplied in the form of on-line help and a user manual in PDF format.
Support is available via the Web, e-mail or phone.
All users of Eligibility Manager share the same global data (health plan settings, ODBC configuration, translation tables, etc.).
See Custom Solutions for samples of custom processes we have implemented.
