Last Modified: 7/7/2018 Location: FL, PR, USVI Business: Part A, Part B
Variances in eligibility data FAQ
Q: Why would the eligibility information returned by the IVR or DDE differ from the eligibility data returned by the SPOT?
A: Although all of First Coast’s “eligibility query systems” are accurate based upon the information available to each, the reasons for any differences in the eligibility data returned by the Secure Provider Online Tool (the SPOT), the Interactive Voice Response (IVR) system, and Direct Data Entry (DDE) are due to key variances among the three systems regarding the following:
• Source of the eligibility data returned
• Query parameters of the eligibility request utilized
• Timing of updates to individual and dependent government databases
In addition, due to the variances listed above as well as the differences in the types and depth of data displayed, the responses to eligibility queries may either be different or only appear to be different.
Eligibility data sources
The Centers for Medicare & Medicaid Services’ (CMS) HIPAA Eligibility Transaction System (HETS) is the source for all eligibility data accessed through First Coast’s Secure Provider Online Tool (the SPOT). The source for HETS’ eligibility data is the CMS eligibility database, which is dependent upon the timely updates of other government databases and systems, including the Social Security Administration (SSA) database.
HETS is a secure, online system that is compliant with Health Insurance Portability and Accountability Act (HIPAA) guidelines. When a user of the SPOT submits an eligibility query, the user is actually initiating a secure, real-time connection with HETS. HETS validates the beneficiary information submitted, obtains Medicare beneficiary eligibility data from the CMS eligibility database, and returns the available eligibility data to the user through the SPOT.
However, if HETS does not return eligibility data for a particular code or if certain data is not available in HETS, the SPOT will also be unable to display that data.
Although the primary source for eligibility information obtained through First Coast’s IVR system is also HETS, the IVR also retrieves some information from the Common Working File (CWF):
• Hospice data
• Home health data, which includes the rendering provider’s PTAN
• Skilled nursing facility (SNF) data
Eligibility information obtained through DDE may vary not only from the data returned by the SPOT and the IVR but also from the data returned by different query mechanisms within DDE. For example, the eligibility information obtained through the DDE inquiry menu (Option 10) displays current Medicare Part A and Part B entitlement and utilization information but is not maintained by the common working file (CWF), which has more current information than is available through alternate sources.
However, Part A users also have the option to use Eligibility A (ELGA), which has at least six pages of detailed eligibility information, and its source for eligibility data is the CWF.
Eligibility query parameters
When a user of the SPOT submits an eligibility query to HETS, the query is based upon a date of service range, which may be up to 12 months in the past and up to four months in the future. However, according to CMS, the data included in the HETS eligibility response should be considered true and accurate only at the time of the query itself.
IVR users have the option to base their eligibility queries either on the current date or on a specific, previous date of service. For more information, please consult the IVR Operating Guide (Part A or Part B). Since the IVR also uses HETS as its source for eligibility data, CMS advises that the data included in the HETS eligibility response should be considered true and accurate only at the time of the query itself.
DDE users set the parameters of their eligibility queries through ELGA based upon either the current date or a specific date of service that occurred up to 180 days in the past. However, ELGA is not compliant with HIPAA, and CMS plans to eventually retire all eligibility query mechanisms currently available through DDE.
Timing of eligibility and other database updates
One common limitation that the SPOT, the IVR, and DDE all share is that the timing of the updates to the databases upon which they depend may greatly affect the currency of the eligibility data available through each as well as the appearance of discrepancies among them.
The variances in the update schedules of the systems themselves as well as their sources for eligibility data may affect which of the three has the most current information available.
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