Online Eligibility Check (OEC)

Cutting Edge Software has two functions for pre-checking a patient's eligibility to claim with their health funds.

Both of these Eligibility functions are accessed from the Account Handling box in the top right of the screen.
Ensure the Invoice Status is set to Estimate then click on 'Check Eligibility' in the Account Handling box.
If there's no button then OEC is not available for that fund or claim type. 

If both functions are available you will be presented with buttons to choose.

The first function is called a Cover check. For this you only need to enter a patient's Medicare and Fund details before clicking Check Eligibility.
A Cover Check will return information from the fund about level of cover, exclusions, restrictions, co-payments etc.

The second function is called Online Eligibility Checking (OEC).

This allow users to send an estimate with the expected items and date of service to Medicare and the patient's health fund to determine the level of cover, expected rebates and any limitations for the items on the invoice.

To use the full OEC function, enter all the patient and procedure details as usual on an invoice before clicking on 'Check Eligibility'. You will then see an OEC dialog where you need to enter expected dates of admission and discharge. These should cover the date of procedure but can be estimates. You also need to select a Presenting Illness Code from the searchable dropdown list on the OEC screen.  When ready click OK and the results will be displayed on the screen and stored in the Invoice History tab so you can review them later.

NOTES:

Cover check can be done at any time. Full OEC can only be done on invoices with date of admission/service not more than 7 days ago.

Results are stored on the History tab, so you can easily review what a previous coverage or OEC response was. Click on the Link icon to view.

Results will vary from fund to fund. Some provide quite detailed information on level of cover while others give limited information and some funds don't support OEC, so you may receive a negative response when you attempt to use the OEC function.

When looking for the presenting illness code, users can just search for a specific presenting illness by typing in the code or a part of the text in the description, instead of scrolling through the entire list each time.

Some funds require an Illness Code in the 4xx range for OEC,  so if your first choice doesn't work select an alternative and try again.

If you don't get the information you require you will need to contact the fund directly. Cutting Edge provides OEC to assist you but cannot vouch for the accuracy - CE simply displays the data we get back from the fund.

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