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How to Run Eligibility and Prior Authorizations in eCW?

How to Run Insurance Eligibility and Prior Authorizations in eClinicalWorks (eCW): Including Jelly Bean Notifications

Managing insurance eligibility and prior authorizations in eClinicalWorks (eCW) is streamlined through its workflow tools, including the Jelly Bean notification system. Jelly Beans ensure your team stays informed about pending tasks, follow-ups, and status updates for both processes. Here’s a complete step-by-step guide:

Step 1: Verify Insurance Eligibility

1. Access the Patient’s Profile:
   • Search for the patient in the Patient Hub using their name, ID, or appointment details.
   • Ensure their demographic and insurance details are updated, including payer name, policy number, and group number.
2. Initiate Eligibility Check:
   • Click on the Eligibility Check option under the patient’s profile or within their appointment details.
   • Select the appropriate payer and click Run Eligibility to electronically verify the patient’s insurance coverage.
3. Review Eligibility Results:
   • The system will display an Eligibility Response, showing coverage details, copay, deductible, and whether prior authorization is required.
   • Any issues, such as inactive policies or discrepancies, will appear as alerts.
4. Jelly Bean Notifications for Follow-Ups:
   • If there’s an issue with the eligibility check, eCW generates a Jelly Bean notification for the billing or front desk team to address the problem.
   • Staff can assign tasks via Jelly Beans, ensuring follow-ups like contacting the payer or the patient to clarify coverage details.
5. Document and Save Findings:
   • Attach the eligibility report to the patient’s record.
   • Add notes in the patient’s file or through the Jelly Bean task system for internal communication.

Step 2: Request Prior Authorization

1. Confirm Prior Authorization Requirements:
   • Check the eligibility response to determine if prior authorization is needed for the planned procedure, medication, or service.
   • If the requirement isn’t clear, contact the payer directly or refer to their authorization policies.
2. Access the Authorization Module:
   • Navigate to the Authorization Request section in the patient’s profile or encounter screen.
3. Submit the Authorization Request:
   • Input the following details into the authorization form:
     • Diagnosis codes (ICD-10).
     • Procedure or service codes (CPT/HCPCS).
     • Supporting documents (e.g., medical notes, lab reports, or imaging).
   • Submit the request electronically via integrated clearinghouses or payer portals in eCW.
4. Monitor Authorization Status:
   • Use the Authorization Tracker to view the status of the request.
   • If the payer requests additional information, Jelly Bean notifications will alert the assigned team member for immediate follow-up.
5. Record the Authorization:
   • Once approved, enter the authorization number and expiration date into the patient’s file.
   • Save the payer’s approval confirmation for billing purposes.

Step 3: Utilize Jelly Bean Notifications to Track Tasks

The Jelly Bean notification system in eCW is a crucial part of the process, keeping your team updated on eligibility and authorization tasks. Here’s how to use it effectively:

• Color-Coded Notifications:
  Each Jelly Bean is color-coded for specific task types, such as eligibility checks, authorization follow-ups, or missing documentation.
• Task Assignments:
  Assign unresolved eligibility issues or pending authorization requests to team members through Jelly Beans. Include notes or deadlines to prioritize tasks.
• Real-Time Updates:
  Jelly Beans alert your team when:
  • Eligibility checks return errors or need manual review.
  • Additional payer information is requested for an authorization.
  • Deadlines for expiring authorizations approach.
• Collaboration:
  Use Jelly Beans to facilitate communication between staff. For example:
  • Front desk staff can flag incomplete patient details for the billing team.
  • The billing team can notify providers of payer requirements for specific authorizations.

Step 4: Finalize and Bill

1. Verify All Steps Are Complete:
   • Confirm that insurance eligibility has been verified and that required authorizations are approved.
   • Check Jelly Bean notifications for any unresolved tasks.
2. Prepare for Billing:
   • Ensure the authorization number and eligibility details are recorded in the billing system.
   • Submit claims with complete and accurate information to avoid denials.

Pro Tips for Efficiency

• Batch Eligibility Checks:
  Run eligibility checks in bulk for all patients scheduled for the day. This ensures coverage issues are identified well in advance.
• Set Jelly Bean Reminders:
  Use Jelly Beans to schedule follow-ups for expiring authorizations or incomplete tasks.
• Templates for Authorization Requests:
  Save time by creating templates for common procedures or services that require prior authorizations.
• Continuous Training:
  Ensure staff are trained to navigate eCW’s tools, including Jelly Beans, for effective workflow management.

What Did We Learn?

By integrating insurance eligibility checks and prior authorizations with eCW’s Jelly Bean notifications, your team can streamline operations, reduce errors, and stay on top of critical tasks. Jelly Beans act as a safety net, ensuring no step is missed, and allow staff to collaborate effectively for better patient care and faster reimbursements.