About eVerification

Note: These prerequisites do not apply to Total INSIGHT clients, as Clinicient staff will perform these steps on your behalf.

Additionally, you may incur transaction fees for use of eVerification as per the contract between Clinicient and your practice.

Before you can utilize eVerification functionality, there are a number of steps you will need to take on the Waystar website with regard to payer enrollment and eligibility name matching. The following steps will need to be taken for each payer to whom you will be submitting verification requests and/or claims:

Payer Enrollment

Some payers require that providers complete enrollment before a clearinghouse or other entity can submit their claims, eligibility inquiries, etc. While enrollment is always required for remits, it is not always required for claims. Prior to attempting to electronically verify benefits, with any payer, you will need to determine if that payer requires enrollment. This can be done through the Waystar Payer List, which can be found here.

When viewing the Payer List, enrollment requirements are indicated by the appearance of the bullet point in each column:

• A solid bullet indicates the payer requires enrollment.
• An empty bullet indicates the payer does not require enrollment.

Waystar (formerly Zirmed) offers a complete step-by-step tutorial to create an enrollment request on page 8 of their Enrollment User Guide, which can be found here.

Eligibility Name Matching

After completing payer enrollment where required, you must also associate both the payer and provider names entered during enrollment with a standard Payer Identification code (Payer ID) and Payer Name uniformly recognized by the Waystar system. step-by-step instructions for completing the name matching process can be found in Waystar's Eligibility Verification User Guide, located here

• Payer Name Matching can be found on Page 26.
• Provider Name Matching can be found on Page 27.

General Billing Data Setup in INSIGHT

Once you have completed the necessary steps with Waystar, you must update the payer information in INSIGHT's Payer Editor.

Click the to open the Payer Editor, then click the General Billing Data tab. Enter the appropriate EDI code for your payer in the EDI Payer ID field, click the Billing Medium field and select Electronic from the drop down list, then click the Save button to save your changes.

The payer’s systems must allow electronic billing and electronic benefits verification. If they are not allowed, then you will need to call the payer to manually verify benefits. Waystar's payer list can be found by clicking here.

To run eVerification, you must first save an active case in the Client Editor that has all the information required to check benefits. You must enter information on both the Personal Information tab and the Case Information tab.

Personal Information tab

The following information must be entered for INSIGHT to verify benefits:

• Date of Birth
• Last Name
• Legal First Name – or the name that is on the insurance member ID card

Case Information tab

The following information must be entered for INSIGHT to verify benefits:

• Facility with an NPI number.
• Discipline of Physical Therapy, Occupation Therapy, or Speech Therapy. If you enter a Supervisor, then INSIGHT automatically enters the Discipline.
• Plan Name
• In or Out of Network
• Patient Relationship to Subscriber
• Member ID

Payer Editor

Generally, payers utilize a single EDI address for both claims and eligibility. Some payers have separate EDI addresses for each. Medicare A and B are examples of these payer types, and will need to be configured for these separate EDI addresses in order to run eVerification in INSIGHT.

Click the to open the Payer Editor, then click the eVerification checkbox located on the Demographics tab. Enter the appropriate separate EDI code for your payer, then Click OK to save your changes and close the Payer Editor.

• For Medicare A and B, the EDI code for eligibility/benefits is Z1073.

After you have entered all the required information in both the Client Editor and the Payer Editor, click Save. INSIGHT is then ready to run eVerification.

To run eVerification, click the button. INSIGHT will then query Waystar for patient benefit information.

INSIGHT displays the following message indicating that it is currently processing:

When the eVerification process has completed successfully, INSIGHT displays the following message:

Medicare Audit Risks

When running eVerification, it's important to note that on the first day of every month, CMS will audit eligibility requests for “high volumes” (per NPI) and repetitive requests (per HIC#/NPI) for the same patient. Audit failures could lead to the eligibility privilege being suspended by CMS for your practice. Please note that CMS has not defined what is considered high volume.

Tip: On the first day of every month, we recommend that your practice be mindful of this eligibility request audit, limit the number of total requests, and avoid repetitive requests.

When will they audit?

CMS states that they will audit provider eligibility volumes being sent via the ANSI X12 270 transaction on the first day of the month and the first Monday of the month.

What will they audit?

1. ‘High volumes’ between the hours of 7AM and 7PM ET. CMS has not specifically defined what they consider to be ‘high volumes’.
2. Repetitive inquiries: Defined as multiple Eligibility requests sent for the same HIC#/NPI combination at any time on the audit days, regardless of the demographic information on the inquiry. Current threshold is 30 or more such repeats.

What are the potential ramifications?

Providers that fail one or both audits could have their NPI-specific access to the HETS system suspended for eligibility inquiries.

What you should do:

1. Avoid sending high volumes of Eligibility requests on the first day of every month and on the first Monday of every month.
2. Avoid sending more than 30 repeats of an Eligibility request on the first day of every month and on the first Monday of every month.

The full Medicare Rules of Behavior can be found here.

After the eVerification process has been successfully run INSIGHT will make several changes in the Payer Information section.

• The Benefits Status field will change to eVerified.
• The button will turn blue, indicating that benefit information is now available to view.

INSIGHT records changes to insurance information in the Change Log. See View Client Record Changes for more information about viewing the change log to see which fields were updated.

INSIGHT attempts to electronically verify and obtain the following information:

• Co Pay amount
• Co Insurance amount
• Total Deductible remaining
• Max Visits Allowed
• If the Deductible Has Been Met
• If the Out of Pocket Has Been Met
• If authorization is required for payment (Auth Required)

Note: INSIGHT verifies patient benefits at the time that eVerification runs. INSIGHT cannot verify benefits that take effect on a future date. Also, while INSIGHT requests this information, the system relies upon the availability and accuracy of the payer’s data.

If Medicare is selected as the primary payer, then INSIGHT also attempts to electronically verify:

• Medicare $ Used amount.
• Used As Of date is the date eVerification runs.

Benefits fields will not automatically populate benefits values in INSIGHT. To view benefits values for manual entry, click on the button and view the exact information that was returned from the payer.

Clicking the button brings up a window displaying the Eligibility Response that Waystar returned from the payer in a separate window. You will be able to view benefits values in this window and enter them in INSIGHT simultaneously.

Note: By default, eVerification will store the last successful response from the payer. If historical responses are required, please contact support and historical responses from the payer will be procured.

INSIGHT submits the following Service Type Code to Waystar based on the discipline entered into INSIGHT:

Service Type Code	INSIGHT Discipline
AF-Speech Therapy	Speech Therapy
AE-Physical Medicine	Physical Therapy
AD-Occupational Therapy	Occupational Therapy

Scroll through the returned benefit information to find the appropriate service type and review the listed benefit information.

You can resubmit insurance information for electronic verification if the information changes or if verification failed the first time due to network issues or other problems.

 

INSIGHT displays messages related to electronic verification of benefits (eVerification) in the Benefits Status field. The table below will help you understand what the messages mean.

Benefits Status Message	Definition
eVerified	INSIGHT was able to connect with Waystar and return what benefits information is electronically available from the Insurer.
Not Covered: eVerification	INSIGHT was able to connect with Waystar and determined that the patient does not have the requested benefitcs (PT, OT, or SLP) through the listed insurer.
Manual Verification Needed	INSIGHT was unable to retrieve benefits information, and benefits will need to be manually verified.
Manually Verified	This status automatically appears when a user manually makes a change to any of the returned benefits fields.
Not Covered: Manually Checked	This is a status you can select when you have manually checked for benefits and found that the patient is not covered for the requested benefits (PT, OT, SLP) through the listed insurer. This status should be selected when you need a claim generated for a service that is not covered. Note that this will not prompt a notification to display on either the Appointments at Risk or the Corrections Queue.
Resubmit eVerification	If you have previously eVerified benefits and then make a change to the payer mix,INSIGHTwill prompt you to resubmit eVerification. If you ignore the message, this status will appear reminding you that you need to resubmit eVerification for the new payer mix.
Submit on Effective Date	The Effective Date listed is in the future. INSIGHT is unable to electronically verify insurance that is not currently active.
eVerification Not Offered: Manual Verification Needed	The insurer listed does not offer eVerification. You will need to manually verify the benefits.
Facility's NPI is missing: Cannot Run eVerification	The Facility chosen does not have a National Provider Identifier (NPI) number associated with it in INSIGHT. This will need to be updated before INSIGHT can attempt to electronically verify benefits.
Incorrect Member ID: Cannot Run eVerification	The member ID is incorrect and must be corrected before INSIGHT can electronically verify the benefits.
Incorrect DOB: Cannot Run eVerification	The Date of Birth (DOB) does not match and will need to be corrected before INSIGHT can electronically verify the benefits.
Incorrect Subscriber Name: Cannot Run eVerification	The subscribers name is incorrect and must be corrected before INSIGHT can electronically verify the benefits.
eVerification failed. Please resubmit again in 24 hours	There was a problem with Waystar's verification service. Please try to verify the benefits again in 24 hours.

If INSIGHT is unable to verify benefits, you will need to call the payer to manually verify benefits. Once you have the information, enter the verified values into INSIGHT.

INSIGHTwill automatically change the Benefit Status field to Manually Verified indicating that benefits information were obtained through a manual process and not electronically verified by INSIGHT.

If INSIGHT cannot or has not run eVerification, if the Benefit Status has not been manually changed to either Manually Verified or Not Covered: Manually Checked, then notifications will display in the Appointments At Risk and Corrections Queue alerting you to the issue. Simply click each issue to be automatically directed to the appropriate place to correct the missing information or manually enter benefit information.

Note: To ensure your Corrections Queue does not display benefit verification issues, always ensure the Benefit Status is set to either Manually Verified or eVerified after verifying benefits.

Cannot Run eVerification

If INSIGHTcannot run eVerification, and you have not manually verified benefits, three days before the next scheduled appointment, INSIGHT will display a message in the Appointments at Risk section stating Cannot Run eVerification and list the incorrect or missing information preventing it from running directly after. Click the message text to go to the appropriate screen to correct or complete missing information.