Data Systems Group | Application Modules: Eligibility Verification

Pre-Billing

The pre-billing module provides the capability to submit claims on the DSG system through the EDS Certs eligibility verification process.

Prevents the billing of non-eligible claims
Identifies Medi-Cal claims that should be billed to a Medi-Cal managed care program, not EDS

All information received from the Certs system is stored in the DSG claim database. In cases where the claim "passed" the appropriate Certs authorization, data is transmitted into the electronic file to ensure claim eligibility and payment.

Medi-Cal Eligibility, Self-Pay

The Medi-Cal Eligibility search module is a stand-alone product that identifies patients who are listed as self-pay or another financial class, but who, in fact, are eligible for Medi-Cal.

First, it receives a file or electronic report of self-pay and/or Medi-Cal pending patients from the hospital host system. Then it formats that file into the required Certs Ansi-270 format. Finally, it submits each record to the EDS Certs eligibility process.

Many DSG clients rely on this product to locate a previously unidentified source of Medi-Cal revenue.

Eligibility and Claims Status - 270/271 & 276/277

DSG processes HIPAA compliant eligibility and claims status transactions with those payers that currently participate in providing 270/271 & 276/277 transaction sets. The process can be run in batch mode prior to staff reviewing the claims, or individually on a claim by claim basis. Results are stored in the DSG claim record for reference and can be exported to upload to the patient accounting system.