Eligibility

Eligibility can be transmitted using PDMI’s standard eligibility layout, which includes all required data elements, or a format selected by the client. We have detailed testing procedures in place to ensure that eligibility is loaded correctly prior to start-up; all error reports are reviewed with the client in a timely fashion.

Because of our proprietary system capabilities, we have developed plan-specific edits to accommodate a wide array of creative eligibility processes. Coupled with a thorough QA process, PDMI has the ability to incorporate client-specific needs for eligibility purposes.

Clients have 24-hour on-line access to view the eligibility status of their plan participants. In addition, we have a real-time interface that clients may utilize to update eligibility in PDMI’s system for instant availability:

• Real-time eligibility interface – Allows clients to initiate data requests/changes to PDMI’s system and receive formatted responses detailing errors or other information requested.
  
  - Includes prior authorizations/overrides/accumulators
   
• Real-time claims interface – Allows PDMI to initiate a connection to the client’s webservice to pass claims data to the client in real-time.

PDMI will accommodate a schedule for eligibility updates that suits every client’s needs. We recommend submitting add/change/delete files daily and a monthly full file that is used to audit the daily transactions for the previous month. Our automated eligibility update procedures contain several checks and balances to ensure the quality of updates. Each file is put through an extensive quality assurance process before posting to the active transaction system. Any discrepancies are reported back to the plan before the file is posted. Similarly, at least once a month, all of our files are run through an additional QA process to identify any discrepancies.

Direct Key & Paper Submission

PDMI’s remote login system enables our clients to login and hand-key membership information directly into our on-line, real-time transaction system; the data is instantly updated.

The paper submission process is keyed through the same system. All required data elements must be completed to ensure that the member is keyed into the system correctly. Audits are performed on all functions. Any record that is hand-keyed into the system can be monitored and reviewed. A time, date, and user stamp is posted along with any changes that were made.