Pass-Back Eligibility Verification: Real-Time Coverage Validation
What Is Pass-Back Eligibility Verification?
Pass-back eligibility verification is a powerful new feature in DocStation that allows you to verify a patient's medical coverage directly within your BIN billing workflow. While real-time eligibility verification is an embedded element of prescription billing, this feature provides immediate verification of a patient's medical insurance status before dispensing products or services.
Why It Matters
Confirming active medical coverage is crucial before billing a product or service to a specific plan. With pass-back eligibility verification, you gain:
Immediate Coverage Confirmation: Know whether a patient has active coverage before dispensing products
Medicare Advantage Coverage: Know if a Medicare beneficiary has Advantage plan coverage in addition to Part B
Reduced Claim Denials: Minimize the risk of post-dispensing claim denials
Streamlined Workflow: Address coverage issues while the patient is still present
Improved Patient Experience: Avoid the frustration of unexpected coverage problems after service
How to Enable Pass-Back Eligibility Verification
This feature is currently opt-in for the DocStation Beta Group and can be easily activated through the RelayHealth integration:
Navigate to your DocStation organization settings, then the Location for which you'd like to enable the feature.
Go to the Data Exchange tab
Click the RelayHealth integration
Toggle the "Enable Pass-Back Eligibility Verification" option to ON
Save your changes
What to Expect
After enabling this feature, DocStation will perform an automatic, real-time eligibility check with every BIN billed claim. DocStation will submit that eligibility check to the plan identified by the PCN submitted on that claim.
Here's what you'll experience during the BIN billing workflow:
Successful Claims
A PAID claim indicates that coverage was successfully verified, giving you confidence to proceed with dispensing. This paid claim will automatically generate a medical claim on DocStation set to submit to that payer.
If a Claim Is Rejected
If the patient's coverage cannot be verified with that payer, the claim will reject and include a message explaining why coverage was not verified. This allows you to address the issue immediately with the patient. Some reasons will be related to actual coverage determinations, while others may be related to EDI enrollments on DocStation. If you are unclear about what to do for the latter, reach out to DocStation support via Chat or at support@docstation.co.
Please note: If the patient has coverage under a different payer, always attempt to bill the PBM first as applicable. If the product or service should still be submitted via the medical benefit, change the PCN on the DocStation coverage of the patient profile to the applicable payer ID. Payer IDs can be provided by DocStation Support or by checking this list.
*Medicare Advantage Coverage Considerations
The claim will also reject if the eligibility check to Medicare Part B detects Medicare Advantage coverage. Review the reject message to see the name of the Medicare Advantage payer, and reprocess the claim to DocStation's BIN with that payer's PCN.
In the beta testing period, you will need to run a separate eligibility check to obtain the subscriber ID for the Medicare Advantage plan. You can do this via the Patient Profile on DocStation. Check out this article to learn more.
Add a new third party insurance record to the patient's profile with:
DocStation's BIN - 025656
Subscriber ID for the Medicare Advantage plan
Resubmit the claim with that new third party record.
Soon, DocStation will automatically include the second eligibility check to obtain the Medicare Advantage subscriber ID in the BIN billing workflow. Stay tuned for more information on the release of that upgrade!
Override Options
If you believe the rejection is an error and the patient does have valid coverage, you can enter the override codes to skip the eligibility check and push the claim directly to DocStation.
To override the eligibility check, select the Intermediary Authorization ID option and enter "OEC" as the value. Then resubmit the claim.
In PioneerRx, the Intermediary Authorization ID can be found in the Overrides tab.
Choose "EX-Intermediary Authorization ID" from the first menu
Change Rx Scope to "This fill only"
Enter the Override Value of "OEC"
Save
In Liberty RXQ, the Intermediary Authorization ID can be found in the Additional Prescription Information section, on the tab NCPDP Fields (2).
Select 1- Intermediary Authorization from the Type menu
Enter the Number "OEC"
Click OK
For other dispensing systems, check with system support to find the Intermediary Authorization Type and ID fields. These fields are typically accessible near DUR/PPS override fields.
Requirements for Use
To utilize the pass-back eligibility verification feature on DocStation, your account must have the following in place:
Active DocStation Base platform subscription
Active DocStation utilization subscription for medical billing
Enabled RelayHealth integration
Current EDI enrollments for all applicable payers
Beta Testing and Full Release
Pass-back eligibility verification is currently in beta and is free to use for all DocStation customers. We anticipate a full feature release in the fall and will communicate additional feature upgrades to any customers who have used the feature.
Questions?
For additional information or assistance with the pass-back eligibility verification feature, please reach out to our support team in the chat or at support@docstation.co.