EHRS-FM IG

ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
0.16.0 - CI Build

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Requirements: AS.9.2 Support Financial Eligibility Verification (Function)

Active as of 2024-08-12
Statement N:

Support interactions with other systems, applications, and modules to enable eligibility verification for health insurance and special programs, including verification of benefits and pre-determination of coverage.

 Description I:

Retrieves information needed to support verification of coverage at the appropriate juncture in the encounter workflow. Improves patient access to covered care and reduces claim denials. When eligibility is verified, the system could prompt a provider to capture eligibility information needed for processing administrative and financial documentation, reports or transactions; updating or flagging any inconsistent data. In addition to health insurance eligibility, this function would support verification of registration in programs and registries, such as chronic care case management and immunization registries. A system would likely verify health insurance eligibility prior to the encounter, but would verify registration in case management or immunization registries during the encounter. Example: A US Realm example could include information about capturing VFC eligibility status as this is a requirement for any provider using federally funded vaccine in the USA.

 Criteria N:
AS.9.2#01 SHOULD

The system SHOULD provide the ability to capture patient health plan eligibility information for date(s) of service.
AS.9.2#02 conditional SHALL

IF the system does not provide the ability to exchange electronic eligibility information (e.g., health plan coverage dates) with internal and external systems, THEN the system SHALL provide the ability to enter and maintain patient health plan coverage dates.
AS.9.2#03 MAY

The system MAY provide the ability to capture general benefit coverage information for patients.
AS.9.2#04 dependent SHOULD

The system SHOULD store eligibility date(s) of service, coverage dates, general benefits and other benefit coverage documentation for service rendered according to scope of practice, organizational policy, and/or jurisdictional law.
AS.9.2#05 MAY

The system MAY provide the ability to capture electronic eligibility information from internal and external systems.
AS.9.2#06 MAY

The system MAY provide the ability to render information received through electronic prescription eligibility checking.
AS.9.2#07 MAY

The system MAY provide the ability to capture and maintain patient registration in special programs (e.g., registries and case management).
AS.9.2#08 MAY

The system MAY provide the ability to analyze eligibility and coverage information for inconsistencies (e.g., coverage dates, patient identity data, coverage status), and render a notification to the user regarding identified inconsistencies.
AS.9.2#09 MAY

The system MAY provide the ability to render information received through provider eligibility checking.