Checking Patient Eligibility

This lesson will discuss checking the patient's prescription eligibilty/formulary.

There are two ways to process Rx eligibility for a patient:

  1. Bulk Download of Rx Eligibility Information
  2. Automatic Rx Eligibility Download by Individual Patient

1.  Automatic Rx Eligibility Download by Individual Patient

1.  Automatic Rx Eligibility Download by Individual Patient

Rx eligibility can be set to retrieve an individual patient's formulary information automatically when the Rx Manager is opened from within the patients chart.  

To turn on automatic Rx formulary eligibility, follow the steps below:

Go to the Tools menu, then click on Options.

  1. Select  Workflow from the left hand menu.
  2. Place a check in the box next to Auto Rx Formulary and Eligibility Retrieval.  

This setting is a global setting and will affect all users when logged into SOAPware.  Therefore, if this setting is turned on, Rx formulary will be automatically checked on a patient when any user opens the patient's Rx Manager.

2.  Bulk Download of Rx Eligibility Information

2.  Bulk Download of Rx Eligibility Information

Rx eligibility can be retrieved in bulk through the Scheduler workspace. When the Bulk Rx Eligibility window is opened, SOAPware will begin processing Rx formulary eligibility for all patients listed on the schedule for the current date.

To process Rx eligibility from the Scheduler workspace, click on the Tools menu and then select Retrieve Rx Eligibility.

Processing Eligibility

Processing Eligibility

When the Bulk Rx Eligibility window is opened, SOAPware will begin processing Rx formulary eligibility for all patients listed on the schedule for the current date.

After processing, each patient will be displayed along with the result that was received. The results will be displayed in three tabs:

  • Needs Attention
  • Processed
  • All

Needs Attention Tab

The Needs Attention tab will display the patients that need to be corrected or reviewed prior to retrieving their Rx eligibility. There are 3 types of results that will be displayed in this tab:

  1. Red Exclamation icon (Invalid Data): Indicates that there is some required demographics information missing on the patient. This information must be entered prior to retrieving eligibility.
  2. Yellow Exclamation icon (Shortened Data): Indicates that some of the required demographic information has exceeded the maximum character length for Rx eligibility requests. The information can still be submitted for eligibility, but will be truncated when processed. Rx eligibility can be retrieved based on the truncated information by clicking the Retrieve Eligibility button.
  3. Red X icon (Error): Indicates that an error occurred while attempting to retrieve eligibility on the patient. To view the error details, the user may hover the mouse over the error icon. (not pictured)

- Correcting Invalid Data

- Correcting Invalid Data

To correct a patient's invalid demographic information, follow the steps below:

  1. Red Shading: The red shading of the patient name indicates that the patient has some invalid demographic data that must be corrected prior to retrieving eligibility.
  2. Edit: Click the Edit (pencil) button to unlock the patient's demographics.  If another user is currently in the same patient's demographics section, a dialog will pop-up to indicate that the demographics cannot be edited at this time.  Once the other user has closed the patient's demographics section, the Edit button will then allow the demographics to be edited from this window.
  3. Correct Invalid Data: A red exclamation icon will be placed next to each field that requires data to be corrected.  Once the appropriate information has been entered, the icon will disappear.
  4. Save: Once all invalid data has been corrected, click the Save button to save the demographic changes.  This will update the demographics in the patient's chart and the patient account.
  5. Retrieve Eligibility: After all invalid data has been corrected and saved, click the Retrieve Eligibility (green downward arrow) button to reprocess the patient's Rx eligibility.

- Reviewing Shortened Data

- Reviewing Shortened Data

To review or edit a patient's truncated demographic information, follow the steps below:

  1. Yellow Shading: The yellow shading of the patient name indicates that the patient has some data that exceeds the maximum character requirements for retrieving eligibility.  The information can still be submitted for eligibility, but will be truncated when processed.
  2. Edit (Optional): If the user wishes to edit the patient's demographic information to shorten it, click the Edit (pencil) button to unlock the patient's demographics.  
  3. Review/Correct Data: A yellow exclamation icon will be placed next to each field that has exceeded the maximum character requirements.  This information can be edited if desired.  If the user does not edit the flagged information, SOAPware will simply truncate the data when eligibility is retrieved.
  4. Save: Click the Save button to save any demographics changes.  This will update the demographics in the patient's chart and the patient account.
  5. Retrieve Eligibility: Click the Retrieve Eligibility (green downward facing arrow) button to process the patient's Rx eligibility using the truncated data (or corrected data if edited).

- Errors

- Errors

There are some errors that could occur while processing a patient's Rx eligibility.  A red X icon will be located next to the patient's name if an error occurred during processing.  To view the details of the error, hover the mouse over the error icon.

Below is a list of two types of errors that may commonly occur:

  1. Unable to load patient. Please try again later.
  2. Unable to connect to the web server. Please check your internet connection or visit www.soapwarestatus.com to check for a SOAPware Internet Service outage.

Processed Tab

The Processed tab will display the list of patients whose eligibility has been successfully retrieved.  Successful retrieval of eligibility includes patients who were found in the Surescripts database, as well as patient's that were not found. *Note: The information received when a patient's eligibility is checked, is determined by the information released by the insurance company.

If there are any differences between the SOAPware demographic information and the insurance company demographic information, they can be viewed by clicking on the patient’s name.

- Overwrite SOAPware Demographic Info with Insurance Company Demographic Info

To overwrite the SOAPware demographics information with the demographics information from the insurance company:

  1. Click the Edit button.
  2. Click the Overwrite button to replace the patient’s SOAPware demographic info with the insurance company demographic info.

All Tab

The All tab will display all patients who are on the schedule for the current date along with the color coded status of each patient's eligibility retrieval.  

Patients whose demographics need attention will be displayed in red or yellow and their demographics will be automatically expanded.  Hovering the mouse over each patient's name will display a description and instructions for the patient.

Retrieve All

Retrieve All

If several edits have been made within the Bulk Rx Eligibility window, click the Retrieve All button to re-process all items marked as Needs Attention.

Click the Close button to close the Bulk Rx Eligibility window.

Rx Eligibility Alert

SOAPware will review the patient demographic and provider information. If there are items that need to be corrected prior to retrieving Rx eligibility, the above dialog will appear. This alert means that some required demographic information is either missing or has exceeded the maximum character length for Rx eligibility requests.

  1. Invalid Data: To correct the invalid information, click the Cancel button and modify the information for the patient or provider as needed. After correcting the invalid information, return to this window to retrieve Rx eligibility.
  2. Shortened Data: If there are items that have exceeded the maximum character length for Rx eligibility requests, the values will be displayed. These values will be shortened upon submission. Click the Retrieve Eligibility button to request eligibility based on the shortened value.

Rx Hub Confirm Changes

Rx Hub Confirm Changes

While checking Rx eligibility, SOAPware will notify the user if the RxHub patient demographic information differs from the demographic information that is stored in the patient's chart.

The information displayed in the SOAPware Data column will show the user the demographic information that is entered into the patient's SOAPware chart.

The inforamiton displayed in the RxHub column will show the user the demographic information that is on file for Rx eligilbity for this patient.

The user should choose what informaiton they would like to keep as part of the patient's demographics in the SOAPware chart.  Place a check next to each piece of demographic information that you wish to keep in the patient's chart.  Once completed, click the Confirm button.

The Eligibility Tabs

The Eligibility Tabs

After checking for eligibility (through either bulk retrieval or individually), several new tabs will appear within the Notes section of Rx Manager. Each tab represents different coverage plans for this patient. Depending on the particular pharmacy benefit manager, the exact date and format returned for any given coverage will vary. At minimum, the type of benefits will be displayed, e.g. retail, PBM (i.e. mail order or both). For example, in the above screenshot, the PBMA coverage supports only mail order.

*Note: The drug prescribed will be checked against the formulary of the tab that is selected at the time of prescribing.

Formulary Load

Formulary Load

Whenever a medication is added or strength is edited, SOAPware will load the appropriate formulary information based on the eligibility tab (coverage plan) that is selected.

Formulary Information

Formulary Information
  1. Displays the formulary status for the prescription.
  2. A summary of the cost for the medication may be displayed in this section.
  3. Indicates if the drug is a brand name or a generic prescription.
  4. Click the drop down to view alternative drugs supported by the selected coverage.

*Note: The information received when a patient's eligibility is checked is determined by the information released by the insurance company.

Off Formulary Medications

Off Formulary Medications

The drug displayed above is not covered under the selected coverage and displays as "Not Reimbursable/Obsolete".