Best Practices

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:

For more information, see Patient Match VerificationPatient Match Verification.

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:

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.

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 RequirementsApplication Certification Requirements 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.

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.

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.

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.

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) 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).