Review the use case document for Eligibility Cycle

[gopi-vitraya]

Please review and comment on the Eligibility Use case document. Link

[mayurilal]

Question: The onus of whom to delegate lies with the Payor. Is this because the different Payer have defined SOPs for this scenario already? Assuming the primary element for delegation is location, will it make it more efficient to reach out to the Payor on Card as default and that Payor identifies if a delegation is necessary based on where service is requested? i.e since the beneficiary is from Kerala if the default set up is that SHA-Kerala's plan & coverage applies, then instead of SHA-Karnatake delegating to SHA-Kerala, why not allow SHA-Kerala to do the delegation? For beneficiaries situated around state borders, it will improve processing time & reduce redundant messages.

[angshu]

delegation can happen to TPAs as well. For such scenario only payor knows whom to delegate.
In PMJAY case, in all probability the provider can identify from the card itself whom to send the request to. For a beneficiary, if request is sent to SHA-kerela, they can 1) delegate to their internal downstream agencies and in that case HCX has no further role 2) if they are using HCX to route/forward to other agencies - the use case handles such cases.
if for some reason, the request is sent to Karnataka (border area), and the patient is getting serviced in Karnataka, then if request is sent to SHA-Karnataka (e.g. a mistake) - then SHA-Karnataka has two options in my view - 1) they know the patient is from Kerela (ie. if SHAs share a common registry of beneficiaries or able to discover so by some internal means - then they can send redirect request - probably @abhimail can share more insights if there is such internal discovery means. Note, PMJAY is portable so it does not depnd on the origin, and I feel we should not rely on provider sending the domicile of the patient. 2) if they can't resolve the patient, then they just respond with error - beneficiary not recognized. Makes sense?

[mayurilal]

Thanks @angshu

My understanding is that TPAs cannot act independently. They should abide by the Payor whom they support. Also one Payor can use services from more than one TPA; change TPA if service is not meeting quality.... Are we proposing that communication between Payor & their TPA(s) also happen via HCX? TPAs to me are inline with the 1st category - internal agency & as you point out HCX should not play a role.

Does portability mean one benefit plan is followed across States? My understanding is there is some local State variation across Payors & generally the home State services the bene best.

As an example, there has to be a check to ensure benefits are not misused. An appendectomy or tooth extraction etc can be done only once. So there needs to be a way to aggregate availed benefits and the simple the process is with few touch points, the easy it will be to keep a check on it for FWA (fraud/waste/abuse) in eligibility determination.

Please confirm / correct me.

[angshu]

1. On portability, specifically for PMJAY the plan is applicable across states. Of course, whether to rebound to another payor is dependent on the policy and the receiving payor is free to indicate (through claim-response error) so.
2. On TPA, yes. The payor needn't route forward through HCX, they can just handle internally .. HCX just kept the protocol open if someone so wishes.
   @abhimail any further info you would like to add