Online Eligibility Checks
There are a number of eligibility checks available.
| Check | Purpose | Availability |
| ECM - Eligibility Check Medicare - Medicare check | Used by hospitals, day surgeries and medical providers to determine whether Medicare covers the patient, and which Medicare benefits are payable for inpatient medical services. | Estimates |
ECF - Eligibility Check Fund - PHI check | Used by hospitals and day surgeries to find out whether the patient is eligible for a selected presenting illness/condition on the admission date. This check provides the out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product. | Pre-admissions Assessments |
| OEC – Online Eligibility Check - Medicare and PHI check | Used by hospitals, day surgeries and medical providers to determine whether the patient is eligible for a selected presenting illness/condition on the admission date. It provides the out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product, and the Medicare and the private health insurer benefits payable for the medical services. Note: This is effectively a combined call for the above two datasets. | Not available (Nov 2022) |
| ECO - Eligibility Check Overseas - PHI check | Used by hospitals and day surgeries to find out whether the patient who is an overseas visitor is eligible for a selected presenting illness/condition on the admission date. This check provides the out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product. | Not available (Nov 2022) |
CareRight has the ability to complete an Online Eligibility Check (OEC) for a patient. This can assist hospitals and day surgeries in determining the patient’s eligibility for a service/s and any out-of-pocket expenses for care. Before a Patient Eligibility Check can be performed, consent must be obtained from the patient or a legally authorized representative.
The OEC will determine whether the patient is eligible for a selected presenting illness/condition as of the admission date. It will detail the out-of-pocket expenses a patient has for excess and co-payments associated with the hospital product.
The OEC process utilizes the Medicare online claiming process. The results presented are in accordance with the Medicare specifications. It does not produce an Informed Financial Consent (IFC) form. The OEC can be performed as part of the Pre-admission process.
| Note: Please note OEC is user permission-based functionality Only users with Can create OEC and IFC can perform this. |
ote: OEC is a permission-based functionality. Only users with Can create OEC and IFC can perform this
Performing an Eligibility Check Fund (ECF) during Pre-Admission
- Access the Patient record.
- Select Admissions from the menu.
- Select the Pre-Admit button.
- The pre-admission screen will display the following fields (use the table below for reference).
Field | Description |
|---|---|
Planned Location | The planned location for this admission |
Planned Date | The planned date for this admission |
Admission Category | Admission category (which will set any pre-defined statutory reporting values for the admission) |
Reason | This is a free text field |
Admitting Doctor | This is a drop-down list which references your organization's Providers. |
Funding Choice | For the OEC to work this must be set to Health Fund |
Presenting Illness MBS Number | Presenting Illness MBS Number refers to the particular type of surgery. |
Presenting Illness Service Code | Presenting Illness Service Code is a 3 digit code |
Additional Services | Additional Services can be added by selecting Add Service button. These may be miscellaneous service code parts This information will flow through into an IHC claim |
Pre Existing Condition (check box) | True or False |
Compensation Claim (check box) | True or False |
| Requires Type C Certificate (Checkbox) | Check if a Type C Certificate is required for this admission. |
Funding Choice | The funding can be selected from the drop-down. |
4. Select Pre-Admit.
5. A message advising that the Patient was successfully pre-admitted with the display.
6. The OEC button will now be present at the top of the screen.
7. Select the OEC button.
8. The OEC screen will display.
9. Fill in any relevant information as requested (these are medicare related fields and not related to CareRight).
- Update additional services button.
- A message advising that CareRight is communicating with the health fund will display.
10. Once the check is completed the standard Medicare eligibility report will display. this can be downloaded and Printed.
11. Any co-payments and the Excess amount is to be added here, Confirmation is required if no co-payment or Excess is taking for this admission. If no co-payment, excess, and/or gap is required, be sure to tick the relevant checkboxes before proceeding with the OEC.
The OEC printout will print the fields as shown;
- Response code (Fund Explanation)
- Pre Existing Condition (from user entry before the claim was sent)
- Compensation Claim (from user entry before the claim was sent)
- Accident Date (from user entry before the claim was sent)
- Accident Indicator (from user entry before the claim was sent - if the user added accident date)
