Automating Medicare Real-Time Eligibility (270/271) for Enhanced Revenue Integrity

Klivira's platform automates Medicare real-time eligibility (270/271) checks, ensuring accurate patient coverage data at every point of service across Original Medicare and Medicare Advantage plans.

In an environment where accurate eligibility is paramount for financial health, relying on batch processes or manual lookups for Medicare members introduces significant risk. Stale data leads to claim denials, delayed payments, and patient dissatisfaction. Klivira addresses these challenges by integrating real-time eligibility verification directly into your existing workflows.

The Challenge of Timely Medicare Eligibility Verification

Traditional eligibility checks for Medicare members often involve batch processes run overnight or manual portal lookups, creating a gap where coverage changes can lead to day-of-service surprises. This is particularly complex given Original Medicare's structure, where Medicare Administrative Contractors (MACs) like Noridian, NGS, WPS, Palmetto, FCSO, and Novitas manage claims in specific jurisdictions, alongside the diverse landscape of Medicare Advantage plans.

Klivira's Real-Time Eligibility Solution for Medicare

Klivira's platform provides event-driven triggers for real-time eligibility checks at critical junctures such as patient registration, appointment check-in, order entry, admission, and transfer. By leveraging both X12 270 real-time transactions and FHIR Coverage queries, we ensure immediate access to the most current Medicare coverage details, whether for Original Medicare or a specific Medicare Advantage plan.

Key Benefits of Automated Medicare Eligibility Verification

**Eliminate Stale Data:** Event-driven re-verification catches coverage changes between scheduling and service.
**Prevent Day-of-Service Surprises:** Eligibility issues are identified and addressed proactively at check-in, avoiding patient friction.
**Reduce Manual Overhead:** Automate manual portal lookups, freeing up front desk and scheduler staff.
**Pre-empt PA Requirements:** When real-time eligibility identifies a prior authorization requirement for a planned service, Klivira can immediately initiate the PA workflow.
**Support for All Medicare Types:** Seamlessly verify eligibility for Original Medicare (Parts A/B) and private Medicare Advantage (Part C) plans.

Navigating Medicare's Structure with Klivira

Original Medicare operates through its designated MACs, while Medicare Advantage plans are administered by private insurers. Klivira's system is designed to navigate these distinct structures, routing eligibility requests appropriately. This ensures comprehensive coverage verification, whether you're querying a MAC for Original Medicare or a commercial payer for a Medicare Advantage member, including Part D pharmacy plans.

Operational Impact: Enhancing Revenue Cycle and Patient Experience

Implementing real-time eligibility significantly improves your revenue cycle by reducing claim denials attributable to invalid or outdated coverage. It also enhances the patient experience by minimizing delays and unexpected financial liabilities at the point of service. As recognized by the CAQH Index, real-time 270/271 transactions represent a mature standard for electronic adoption, driving efficiency.

Frequently asked questions

How does Klivira handle eligibility for both Original Medicare and Medicare Advantage?

Klivira's platform is designed to query both Original Medicare and Medicare Advantage plans. For Original Medicare, it interfaces with the relevant systems of Medicare Administrative Contractors (MACs). For Medicare Advantage, it connects to the commercial payers administering those plans, ensuring comprehensive eligibility verification regardless of the Medicare type.

What information is returned during a Medicare real-time eligibility check?

A real-time eligibility check via X12 270/271 or FHIR Coverage typically returns details such as active coverage status, effective dates, plan type, patient responsibility (e.g., deductibles, co-pays, co-insurance), and sometimes specific benefit limitations or prior authorization requirements for certain services.

Can real-time eligibility help with Medicare Part D pharmacy benefits?

Yes, while Part D plans are administered by commercial insurers, Klivira's real-time eligibility can verify coverage under these plans. This helps ensure patients have active pharmacy benefits and can identify if specific medications require prior authorization under their Part D formulary.

How does Klivira integrate Medicare real-time eligibility into our EMR?

Klivira integrates directly with your EMR via SMART on FHIR or other standard APIs, surfacing eligibility details within your existing registration and check-in workflows. This allows staff to view and act on real-time coverage information without leaving the EMR, streamlining front desk operations and scheduler integration.

What standards does Klivira use for Medicare real-time eligibility?

Klivira utilizes industry-standard protocols for real-time eligibility, including X12 270/271 transactions and FHIR Coverage queries. These standards facilitate rapid, secure data exchange with payers, ensuring accurate and timely responses for Medicare eligibility verification.