Application Certification Requirements

general eligibility acrs note this section applies to general eligibility only for eligibility for pharmacy acrs, see eligibility for pharmacy acrs docid\ mnrieqkq0lo85h9ytmiro eligibility retrieval e 100 the participant shall ensure an eligibility request is associated with a patient interaction, is part of a medication reconciliation, or is associated with the electronic prior authorization process definition of patient interaction “patient interaction with the prescriber with the probability that a prescription will take place in the course of that interaction the interaction can take the form of a physical visit, phone call, telemedicine, or email from the patient to the prescriber/prescriber to the patient the eligibility request generally occurs within 24 hours prior to the patient interaction ” examples of what is not considered a patient interaction for the purposes of a billable eligibility request activities associated with health care operations, including but not limited to calls to schedule or check in appointments opening a chart for billing questions reference purposes post visit transcription updating patient information clinical information activities not associated with a prescribing medication reconciliation or electronic prior authorization process, including but not limited to lab test results or follow up post visit reviews coordination of care e 101 participants shall ensure that information returned in the eligibility response shall be used within 3 calendar days/72 hours of receipt eligibility requests are sent only once during that period (unless an error is encountered in the eligibility retrieval process) definition a calendar day runs from 12 00 a m to 11 59 p m central time, regardless of the location of the patient encounter e 102 participant/pbm must be able to process any valid 270 request and 271 response (valid data elements and values, including optional elements, supported by x12 must not cause processing failure at the end point) e 109 pbms that support the “future effective date” in the mpi load file shall return a patient's coverage status based upon the eligibility “date of service” field (dtp01=291 in the 2100c loop eligibility request) presentation of eligibility information e 103 the participant application shall display the following information returned in the eligibility response for an active coverage pbm/payer name (nm103 loop 2100a) all pharmacy coverage types received (e g retail) with associated eligibility status (e g covered/not covered) if displaying pharmacy coverage types that are not received in the eligibility response, the associated eligibility statuses must be clearly differentiated from the eligibility statuses of the pharmacy coverage types that are received health plan name returned in the plan coverage description data element in the 2110c1 loop e 104 the application shall allow the user to switch between all active, eligibility coverages e 105 when the change flag is present, at a minimum, the participant application shall display an alert indicating there is a difference between the patient demographics sent in the 270 and those returned in the 271 for all active coverages and shall make all of the demographics returned available for the prescriber to review e 106 1 when available, pbms shall send the health plan name in the plan coverage description data element in the 2110c1 loop in the eligibility response transaction along with the following plan elements (bin/iin, pcn, group id/name, plan id) and formulary file ids note when sending the health plan name, it is recommended to avoid using acronyms, abbreviations, or random letters and numbers entering a detailed, easy to identify and read health plan name will aid in plan identification eligibility for pharmacy acrs note the acrs below apply to eligibility for pharmacy for more information on eligibility for pharmacy, see appendix a eligibility for pharmacy docid\ r ump6z5lieleoyytsf2d for general eligibility acrs, see general eligibility acrs docid\ mnrieqkq0lo85h9ytmiro eligibility retrieval e 102 participant/pbm must be able to process any valid 270 request and 271 response (valid data elements and values, including optional elements, supported by ansi x12 must not cause processing failure at the end point) e 107 the participant shall ensure an eligibility request is associated with a patient interaction and is part of the process of dispensing and filling the medication definition of patient interaction “patient interaction with the pharmacist with the probability that a prescription will be filled as a result of that interaction the interaction can take the form of a physical visit or phone call ” examples of what is not considered a patient interaction for the purposes of a billable eligibility request activities associated with health care operations, including but not limited to reconciling claims after adjudication has been completed presentation of eligibility information e 103 the participant application shall display the following information returned in the eligibility response for an active coverage pbm/payer name (nm103 loop 2100a) all pharmacy coverage types received (e g retail) with associated eligibility status (e g covered/not covered) if displaying pharmacy coverage types that are not received in the eligibility response, the associated eligibility statuses must be clearly differentiated from the eligibility statuses of the pharmacy coverage types that are received health plan name returned in the plan coverage description data element in the 2110c1 loop e 104 the application shall allow the user to switch between all active, eligibility coverages e 108 when there is a difference between the patient demographics sent in the request and those returned in the response for all active coverages, the application shall make all of the demographics returned available to review