Checking Patient Rx 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. Individual Patient Download

*REQUIRED FOR MEANINGFUL USE MENU SET OBJECTIVE: FORMULARY CHECKS: Click here for Meaningful Use Criteria

1.  Bulk Download of Rx Eligibility Information

1.  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.

- 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 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 button to reprocess the patient's Rx eligibility.

- Reviewing Shortened Data

- Reviewing Shortened Data

To review or edit a patient's truncated demographic information, following 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 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 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

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 patients 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.

2.  Individual Download - Single Patient Matching

2.  Individual Download - Single Patient Matching

Eligibility can also be checked from the individual patient's chart in the Rx Manager. To check the eligibility on a individual patient, Click on the "Retrieve Eligibility Info" button.

*Note: While eligibility information can be checked for an individual patient at the point of care, we advise using the Bulk Eligibility functionality so that the patient's eligibility can be retrieved prior to the clinician seeing the patient.  

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.

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 the 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 screen shot, 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 Information

  1. Displays the formulary status for the prescription. In this case it is "On Formulary".
  2. A summary of the cost for the medication may be displayed in this section.
  3. Information as to OTC/brand and generic/prescription status.
  4. Alternative drugs supported by the selected coverage.
  5. Displays an additional window that may contain more detailed formulary information.

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

Additional Formulary Details

Additional Formulary Details

To view more detailed formulary information, click on the "Coverage Details" button (#5 above).

Off Formulary Medications

This above drug is not covered under the selected coverage and displays as "Off Formulary" and "Brand OTC".