Best Practices

patient demographic detail customers requesting eligibility should send in the most up to date and complete patient demographic information to ensure the highest probability of receiving patient benefit information in return entering accurate patient information will aid in identification of the patient’s benefit information prior to prescribing these fields are utilized by the surescripts matching algorithm to locate patient coverage in the master patient index patient first name patient middle name patient last name patient suffix patient date of birth patient gender patient address line 1 patient address line 2 patient city patient state patient zip code for more information, see patient match verification docid\ kvl cfgz1yemd 5z8ycp8 eligibility response fields eligibility responses include key fields that inform a provider’s decision when writing a prescription and during the dispensing of the medication at the pharmacy absence of key fields causes downstream workflow issues like the inability to accurately tie the active formulary results from the coverage selected leading to lower provider satisfaction and leads to negative patient outcomes key fields include active coverage plan coverage description (health plan name) iin (previously bin) pcn group id (group number) group name plan id ncpdp id formulary status list id coverage id alternatives id copay id person code cardholder id entity identifier code (loop 2120c subscriber benefit related entity name) insurance type code returning all critical fields will result in a better experience for everyone involved in the prescribing process in addition to sending the above fields, the contents should be human readable for the plan coverage description (health plan name) and group name this aids in efficient and effective processing of a patient’s prescription from provider to pharmacy when providing the formulary identifiers (formulary status, coverage, alternatives, & copay) on eligibility responses, it is paramount to ensure they match to the active formulary list ids provided in your formulary data robust formulary accurately informs the provider when prescribing and when the formulary ids are not present in either (formulary or eligibility) responses it prevents this process note to aid in matching, case sensitivity is required for the formulary identifiers (formulary status, coverage, alternatives, & copay) eligibility request utilization eligibility requests generally should correspond closely to the number of scripts being written or processed at a pharmacy per acr e 100 and e 101, eligibility shall be sent once in 3 days in conjunction with a scheduled outpatient visit or treatment event see application certification requirements docid\ mnrieqkq0lo85h9ytmiro for more information to assist in ensuring appropriate processing, interfaces can prevent multiple attempts to manually request eligibility via pop up indicator or greying out of the “check benefit” button after the initial request has been placed benefitscoordination elements data from eligibility responses is used to populate the first benefitscoordination segment within the routing message (newrx) with the associated benefit information from the pbm/payer if more than one active coverage is returned, only the single coverage information utilized to write the prescription is sent subsequent benefitscoordination elements should be used for coupon/discount information in the eligibility response, the isa13 control number shall be populated in the first benefitscoordination segment within the payeridentification/mutuallydefined field, even if there is no active coverage listed in that eligibility response prescriber vendors who are not utilizing the surescripts eligibility request/eligibility response messages should use the first benefitscoordination element for coupon/discount information subscriber – unique identification the subscriber is a person who can be uniquely identified to an information source by a unique member identification number (which may include a unique suffix to the primary policy holder's identification number) the subscriber may or may not be the patient reference asc x12n/005010x279a1 health care eligibility benefit inquiry and response (270/271) sec 1 4 2 page 5 for example, joe johnson is the primary policy holder and has a member id 555123 he is considered a subscriber joe's wife, jane johnson, is covered under joe's policy and has a member id 555124 both joe and jane are considered subscribers because they have unique member id numbers since pbm/payers uniquely identify each member, the subscriber level should be used instead of the dependent level however, receivers of the eligibility request need to be able to handle patients at the dependent level since the standard allows it if the patient is submitted in the dependent loop (in eligibility request), the patient information must be returned in the subscriber loop (in eligibility response) this is due to the fact that pbm/payer's assign unique identifiers to all members thus they are deemed to be subscribers according to the standard iin (issuer identification number) truncation per ncpdp, since 8 digit iins are now being assigned, use the first 6 digits of the iin as the bin even if the first digit(s) is a zero once new version of the ncpdp telecommunication standard is adopted, truncation will no longer be necessary refer to ncpdp processor id (bin) https //www ncpdp org/ncpdp/media/pdf/resources/ncpdp processor id (bin) pdf?ext= pdf for more information for example, an iin that is 8 digits (e g , 12345600) will be truncated to include the first 6 digits (e g , 123456)