Determine Eligibility
Determine EligibilityClicking Request in the menu under Eligibility allows you to submit a request for a client's eligibility details. The requests may be submitted for an individual Provider or a Provider Group. Requests are made directly to NY Medicaid and, therefore, Eligibility Responses may be considered real-time transactions.
There are two eligibility request types:
Client ID—Search using client ID.
Client Information—Search using client information such as name and Social Security number.
Entering the value for one type of request locks out the other request type until either a search is performed or the initial entry field is cleared. For example, entering a value in the Client ID field locks out the Client Information fields. This prevents submitting both sets of request criteria for a single search.
Regardless of the specific eligibility request used, the Date of Service must always be specified. There is also the option to specify the Ordering or Referring Provider NPI, and one or more Service Types to narrow the results.
Client ID Eligibility Requests are the simplest of the two requests because they require only one field.
Enter Client ID: The Client ID of the individual.
Client Information Eligibility Requests are used when the Client ID is not available. All five fields are required.
Last Name/First Name: Enter the client's full name as only complete matches will be successfully processed. Valid values are: A–Z, hyphen (-), period (.), and apostrophe (').
Date of Birth: The Date of Birth entry format is mm/dd/yyyy and may be directly specified or selected using the Calendar control to the right of the field.
Gender: Select Male or Female from the drop-down.
SSN: The Social Security number field is set up to match the standard format of three digits, hypen, two digits, hyphen, four digits (xxx-xx-xxxx) to aid in entering the value.
County Code: The County Code field is a two digit value to be used only by School Supportive Health Service Program (SSHSP) providers. Do not enter an SSN if using the County Code.
The following fields may be populated for either a Client ID or Name Search Eligibility Request.
The Date of Service field must always be specified.
Date of Service: The date of service defaults to the current date, but may be changed. However, the date entered may not be in the future nor be greater than 2 years prior to the current date. The accepted entry format is mm/dd/yyyy and may be directly specified or selected using the Calendar control to the right of the field.
The Ordering/Referring Provider NPI and Service Types fields may be optionally specified.
Ordering Provider NPI: The 10-digit National Provider ID.
Service Types: The applicable Service Type(s) selected from the full list of service types. If no Service Type is specified, the default value of 30 - Health Benefit Plan Coverage is used.
Services Types are specified using the Services Types control. The control consists of two lists—Available for Submission and Selected for Submission—separated by arrow buttons for moving the types between the two lists. The single arrows move one or more types; the double arrow buttons move all members of a list.
Moving a Service Type to the Selected list makes it an addtional field that must be matched for the eligibility request.Services Types can be selected individually for submission by clicking on a type in the Available list and using the right pointing arrow button. The reverse for removing a service type is done by selecting the service type from the Selected list and using the left facing arrow button.
Multiple types can be selected continuously using the Shift key while clicking the types to select an inclusive range or discontinuously using the Ctrl key to select individual types that will moved together.
The Filter function allows the Available types to be limited by entering a value that must appear in a type's description. Only types containing that value will be displayed for selection. For example, entering medi limits the displayed types to those containing medi such as 1 - Medical Care and 55 - Major Medical.
Clicking Submit at the bottom of the page transmits the selected Eligibility Request fields along with any of the optional fields to the NY Medicaid system. A message Request has been submitted. displays above the request fields to indicate the request is complete. Once submitted, the fields are cleared to allow for another request.
The result of the request is available by clicking Responses in the menu under Eligibility.
