eauthorization - eclaimlink manual 2… · after logging in from the login section on the main...

eAuthorizationProviders’ e-Authorization Application on eClaimLink

SEPTEMBER 2016

www.eclaimlink.ae

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in partnership with

Table of Contents

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Getting Started 3

Registration 4

Logging In 5

Prior Request Form 6

Eligibility 7

Submit Prior Request Form 9


Authorization 10

Submit Prior Request Form 15


Error Alert Example 16

Transactions Summary Table 18

Summary Table 18

Prior Request Details 20

Actions 24

Closing the window \ Printing 24

eClaimLink is the eClaim project of the Dubai Health Authority implemented in partnership withDimensions Healthcare with the objectives of establishing a unified standard healthcare languagecommunicated across the emirate, implementing a unified structured communication schema,providing a centralized health data tracking system, facilitating eClaim financial and clinicalinformation between payers, providers, patients & authorities. Empowering the Dubai HealthAuthority with the needed information to organize, strategize, and optimize the healthcare settingin Dubai. The eClaimLink portal is intended to manage eClaims and health data. In addition, it willserve to connect all the healthcare community of Dubai and through its many anticipated moduleswill raise the quality of care, enhance efficiency, and reduce mistakes, fraud and abuse in theEmirate of Dubai. Visit www.eclaimlink.ae for more information.

Response Interpretation 25

Transactions List 31

Filter Transactions 31

List Content 32

Exit the Page 33

Support 34

eAuthorization

http://www.eclaimlink.ae/

Getting Started

Accessing the eClaimLink system requiresthat your facility to be equipped with acomputer and an internet connection.

To get started, open your internet browserand navigate to the following website:

www.eclaimlink.ae

You will then be directed to the eClaimLinkmain website.

On the upper left corner of the page, you willfind a login form, click to register your facilityif you are a new user.

If already registered on eClaimLink pleaseenter your facility’s username and password,then click Log In. Then skip page 4 and godirectly to page 5 of this manual.

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eAuthorization

http://www.eclaimlink.ae/

Registration

If you are a new user, to register you needto have a valid license with one of thehealth authorities or the MOH (ministry ofhealth) in the UAE.

Register your licensed pharmacy oneClaimLink by clicking ‘Click to register’ inthe login section on the main page. If youare part of a group of pharmacies, eachone needs to be registered on eClaimLink.You must only use the account of thefacility in which you are practicing.

Enter all requested information in theform. After validation for your ID is done,your account shall be activated and youshould receive a notification through theemail you registered with.

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eAuthorization

Logging In

After logging in from the login section onthe main page, click on the Applicationsbutton to open the Applications page.

Locate the New Applications box andclick ‘Login to eAuthorization system’.

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eAuthorization

Prior Request Form

This page contains the e-Authorization form to be filled out.

Important information to remember when filling out this form:

• Required fields are marked with an asterisk*

• Pre-defined list – For all fields that have a pre-defined list, you can start typing a few characters in the field andthe system will auto-generate a drop-down list of suggested values to choose from.

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eRxPhysicianeAuthorization

Prior Request Form

The Prior Request Form contains two transaction types: Eligibility and Authorization.

Eligibility Transactions that check whether the patient is an eligible member within its Insurance Company managedportfolio. It only validates the member ID and does not provide an authorization of a specific service.

Authorization Transactions which include eligibility checks, as well as diagnosis and activities details for a specificservice. The provided authorization for these requests take into consideration member eligibility, coverage, limits,and clinical reviews.

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eAuthorization

Prior Request Form

ELIGIBILITY

To know if the card holder is eligible the facility needs to request the following from thepatient and enter them in their appropriate fields in the system:

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Transaction Type: Eligibility or Authorization Encounter Type: Pre-defined list - Select type of encounter from pre-defined dropdown listDate ordered*: Date of submission of transactionPatient Name: Patient name (only for internal tracking purposes)Patient ID: Patient file number at the facilityContact Number: Patient mobile numberMember ID*: Unique reference ID of the patient. This can be the insurance ID as shown on the patient’s insurance card, or another unique identifier of the member.Plan(Payer/Receiver)* : Pre-defined list -The patient correspondent plan at the insurance company. Emirates ID*: National Emirates ID or select reason if not available.

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Prior Request Form

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SUBMIT PRIOR REQUEST FORM:

Request Authorization – Click this button located at thebottom of the page to request for authorization on thepatient’s eligibility from their insurance company, aftercompletion of the prior request form. When you clickon this button, a small message is displayed on thescreen confirming that your request was sent, saying‘Successful Request’. Click ‘OK’ to acknowledge this. Thesystem will line up the prior requests in the order theywere submitted along with their relevant information inthe queue of submitted transactions on the right pane.

The status of the request will initially be Pending until aresponse from the Insurance Company is received.

Clear – Alternatively, click this button located at thebottom of the page to clear the content of the priorrequest form.

eAuthorization

Prior Request Form

AUTHORIZATION

To request an eAuthorization you should complete the information in the following 3 sections:

• Patient & Encounter Information

• Diagnosis Information

• Activities Information

Only when selecting the transaction of type Authorization will the user be able to view the complete form including its three sections.

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Prior Request Form

Section 1: Patient & Encounter information

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Please see page 7 for the definitions of the fields for this section. This fields for this section are the same as found in the Eligibility transaction type.

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Prior Request Form

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Type*: Primary, Admitting, or Secondary. Only one Primary Diagnosis or Admitting is allowed, but you can add several Secondary diagnosis.

Diagnosis Code with Description*: Pre-defined list - Enter the ICD10-CM code if you know it or enter keywords of the diagnosis description you are seeking and the system will show you a short list of related diagnosis descriptions and codes to select from. The more specific, the better the return results from the system.

eAuthorization

Section 2: Diagnosis information

Prior Request Form

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Type: Pre-defined list - Type of the activity: CPT (for procedures including operations, labs and radiology), Dental,Drug, Service (including consultation), and HCPCS (consumable and disposables)Activity*: Pre-defined list - Enter code or search by entering a keyword to search for the needed code or descriptionStart: Start date of the activity /serviceQuantity*: The number of Activities servedNet*: The net charges billed by the provider to the insurance company for this activityClinician*: Pre-defined list - Physician supervising the activities in this encounter

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Section 3: Activities information

Prior Request Form

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Observation(s) are part of activities and are not mandated except in certain cases.

This must be exactly same as reported by treating doctor.

Type: Pre-defined list - One of the listed types to be selected: LOINC, Text, File, Universal Dental, Financial, Grouping,ERX, Result.

Code (Pre-defined list), Value and Value Type vary depending on the observation type and nature of data.

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Section 3: Activities information

Prior Request Form

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SUBMIT PRIOR REQUEST FORM:

Request Authorization – Click this button located at the bottom of the page to request for authorization on theactivities from the patient’s insurance company after completion of the prior request form. When you click on thisbutton, a small message is displayed on the screen confirming that your request was sent, saying ‘SuccessfulRequest’. Click ‘OK’ to acknowledge this. The system will line up the prior requests in the order they were submittedalong with their relevant information in the queue of submitted transactions on the right pane.

The status of the request will initially be Pending until a response from the Insurance Company is received, in whichthe status will then be changed to Received.

Clear – Alternatively, click this button located at the bottom of the page to clear the content of the prior requestform.

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Prior Request Form

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Invalid Clinician: Error may encounter if Clinician ID/Name is not selected from the drop down list or manuallyentered in the Clinician field.

Action to be taken: Clinician ID/Name should be selected from drop down list.

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ERROR ALERT EXAMPLES

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Invalid Activity: Error may encounter if Activity Type is added prior to attaching a file

Action to be taken: Activity Type should be selected prior to attaching any file. Attachment requires PDF format and only maximum of 5MB is allowed.

eAuthorization

Prior Request Form

Transactions Summary Table

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SUMMARY TABLE:

On the right side of the Prior Request Form is a small tablecontaining some information related to the last 5transactions sent.

Details included in table:

1. Member ID – Unique reference ID of the patientreceiving the e-Authorization. This can be the insuranceID as shown on the patient’s insurance card, or anotherunique identifier of the member.

2. Authorization ID – A unique number generated by thesystem for each authorization request.

3. Status – A small message displaying the current statusof each authorization request.

4. Type – Eligibility or Authorization

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5. Action – When you receive a response from the payer on the authorization request, you have the option to takeone of the following actions:

• Cancel – The Prior Request sent will be fully cancelled.

• Edit – The original Prior Request will be cancelled and a new Prior Request form will appear auto-populated with the previously entered information, to be resubmitted.

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PRIOR REQUEST DETAILS:

Click on Show details also located in the Action column to view the details for each submission.

The Details include the following:

1. General Details:

• Transaction ID – System-generated transaction ID number• Transaction Type – Eligibility or Authorization• Encounter Type – Select type of encounter from pre-defined dropdown list• Date ordered – Date of transaction submission• Patient Name – Patient name (only for internal tracking purposes)• Patient ID – Patient file number at the facility

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• Member ID – Member insurance ID as exactly provided on Insurance Card• Emirates ID – National Emirates ID• Request time – Time of transaction submission• Response Time – Time when received the payer response• Download Time – Time when the transaction was downloaded• Cancel Time – Time when transaction was cancelled• Insurance Plan – Patient’s insurance plan (includes payer and receiver)• Authorization ref# (ID Payer) – Number generated by the payer system for the Authorization• Result – The answer of the inquiry – Yes or No

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• Start – Date and time in which activity started• End – Date and time in which activity ended• Limit – Identifies Authorization Limit• Denial – The denial code if the claim is denied by the payer• Comments – Reason(s) for denial would be included here• Actions- Advised transaction status

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2. Diagnosis Details: A list of the Diagnoses. For each entry the type is listed (as primary or secondary) in additionto the code and description

3. Activities: A list of all the activities and their related information. The status of each activity is shown here;whether it was accepted or rejected by the insurance company

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ACTIONSSame action buttons as found on the summary table, to allow actions to be taken from this screen as well

CLOSING THE WINDOW \ PRINTING

• To close this window, click on Close located in the top right of the window, or use the ‘Esc’ Key on the keyboard.• To print this page, click on Click to Print this Screen also located in the top right of the window.

eAuthorization

Response Interpretation

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DENIAL CODE DENIAL DESSCRIPTION

ELIG-001 Patient is not a covered member

ELIG-005 Services performed after the last date of coverage

ELIG-006 Services performed prior to the effective date of coverage

ELIG-007 Services performed by a non-network provider

AUTH-001 Prior approval is required and was not obtained

AUTH-003 Prior Authorization Number is invalid

AUTH-004 Service(s) is (are) performed outside authorization validity date

AUTH-005 Claim information is inconsistent with pre-certified/authorized services

AUTH-006 Alert drug - drug interaction or drug is contra-indicated

AUTH-007 Drug duplicate therapy

AUTH-008 Inappropriate drug dose

AUTH-009 Prescription out of date

eAuthorization

Below is a list of the denial codes and their descriptions that will be used by the payers on the activity level in orderto justify any rejection


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DENIAL CODE DENIAL DESCRIPTION

AUTH-010 Authorization request overlaps or is within the period of another paid claim or approved authorization

AUTH-011 Waiting period on pre-existing / specific conditions

BENX-002 Benefit maximum for this time period or occurrence has been reached

BENX-005 Annual limit/sublimit amount exceeded

CLAI-007 Claim is a work-related injury/illness and thus the liability of the employer

CLAI-008 Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay

CLAI-009 Date of birth follows the date of service

CLAI-010 Date of death precedes the date of service

CLAI-011 Inpatient admission spans multiple rate periods. Resubmit separate claims

CLAI-012 Submission not compliant with contractual agreement between provider & payer

CLAI-014 Claim not compliant with Resubmission type (used only for resubmissions)

CLAI-017 Services not available on direct billing

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DENIAL CODE DENIAL DESCRIPTION

CLAI-018 Claims Recalled By Provider

CODE-010 Activity/diagnosis inconsistent with clinician specialty

CODE-012 Encounter type inconsistent with service(s) / diagnosis

CODE-013 Invalid principal diagnosis

CODE-014 Activity/diagnosis is inconsistent with the patient's age/gender

CODE-015 Activity/diagnosis is inconsistent with the provider type

DUPL-001 Claim is a duplicate based on service codes and dates

DUPL-002 Payment already made for same/similar service within set time frame

MNEC-003 Service is not clinically indicated based on good clinical practice

MNEC-004 Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities

MNEC-005 Service/supply may be appropriate, but too frequent

MNEC-006 Alternative service should have been utilized

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NCOV-001 Diagnosis(es) is (are) not covered

NCOV-002 Pre-existing conditions are not covered

NCOV-003 Service(s) is (are) not covered

NCOV-025 Service(s) is (are) not performed (used after audit)

PRCE-001 Calculation discrepancy

PRCE-002 Payment is included in the allowance for another service

PRCE-003 Recovery of Payment

PRCE-006 Consultation within free follow up period

PRCE-007 Service has no contract price

PRCE-008 Multiple procedure payment rules incorrectly applied

PRCE-009 Charges inconsistent with clinician specialty

PRCE-010 Use bundled code

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PRCE-011 Discount discrepancy

TIME-001 Time limit for submission has expired

TIME-002 Requested additional information was not received or was not received within time limit

TIME-003 Appeal procedures not followed or time limits not met

COPY-001 Deductible/co-pay not collected from member

SURC-001 Sever drug - drug interaction

SURC-002 Sever drug - age contraindication

SURC-003 Sever drug - gender contraindication

SURC-004 Sever drug - diagnosis contraindication

SURC-005 Sever procedure\service - diagnosis contraindication

SURC-006 Sever procedure\service - drug contraindication

SURC-007 Sever procedure\service - procedure contraindication

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eAuthorization


PRCE-011 Discount discrepancy

TIME-001 Time limit for submission has expired

TIME-002 Requested additional information was not received or was not received within time limit

TIME-003 Appeal procedures not followed or time limits not met

COPY-001 Deductible/co-pay not collected from member

SURC-001 Sever drug - drug interaction

SURC-002 Sever drug - age contraindication

SURC-003 Sever drug - gender contraindication

SURC-004 Sever drug - diagnosis contraindication

SURC-005 Sever procedure\service - diagnosis contraindication

SURC-006 Sever procedure\service - drug contraindication

SURC-007 Sever procedure\service - procedure contraindication

SURC-008 Serious safety issue with drug dose

WRNG-001 Wrong submission, receiver is not responsible for the payer within this transaction submission.

eAuthorization


Transactions List

This is a more detailed table containing a list of the submitted transactions. Navigate to this page by clicking on theTransactions List icon located on the top left of the page that contains the Prior Request form.

FILTER TRANSACTIONS

You can search for transactions using any of the following search criteria to filter your results:• ID – System-generated ID for the submitted transaction• ID Payer• Member ID• Plan – Insurance plan for the patient• From – Choose a date from which to begin the search (select a date from the drop-down calendar)• To – Choose a date at which to end your search results (select from the drop-down calendar)• Status – Choose from the pre-defined set of authorization statuses from the drop-down list

When finished entering the search criteria click on the Filter icon.

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Transactions List

LIST CONTENT

The Transactions List contains the followinginformation for each submittedprescription:1. Member ID2. ID – Transaction ID generated

automatically by the system using thefollowing format:(Facility ID_PayerID_unique numberauto generated by the system).

3. Transaction Date – Date and time thatthe transaction was submitted to theDHPO.

4. Insurance Plan5. ID Payer – ID assigned by the payer for

the authorization

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eAuthorization

Transactions List

5. Status – current status of the transaction.6. Response Time – Time it took for the Payer to send the eAuthorization response7. Type – Eligibility or Authorization8. Username – Username of the facility on eClaimLink9. Details – Click on the Show Details icon to view further detail on the transaction10. My Action – Shows the action that was taken:

• Pending – no response yet from payer• Cancelled – This indicates that you have cancelled the transaction after receiving a response from the

Payer. You can click on the ‘request again’ icon to refill the prior request form with the PriorRequest detailsand request for authorization again

• Eligible / Ineligible – Eligibility response from payer was received and result is displayed here. You have theoption to cancel or edit the prior request form

• Authorized Full / Authorized Partial / Authorized Rejected – Authorization response from payer wasreceived and result is displayed here. You have the option to cancel or edit the prior request form

EXIT THE PAGE

To exit this page and return to the Prior Request form, click of the Prior Request button located on the top left side of

this page. 33

eAuthorization

Support

The eClaimLink System is a user-friendly platform built around the true needs of payers, providers, andregulators in the United Arab Emirates.

If you have any inquiries, please call us at:

Dimensions Healthcare – Contact Call Center

Failure to access system, login issues, functionality related inquiries, etc.

600 522 004

[email protected]

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eAuthorization

eauthorization - eclaimlink manual 2… · after logging in from the login section on the main...

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