Certain services may offer better coverage based on the patient’s clinical history, resulting in lower patient responsibilities. Policies may limit the number of times care can be provided within a period. Bridge’s system can process clinical information during an eligibility request.

Behavior

Service Eligibility

When a Service Eligibility request is made, and clinicalInfo is included, Bridge will inspect the policy against payer support.

If there is potential support, the Service Eligibility will contain an array of ConditionalPatientResponsibility objects. Each will describe why it was matched against the request, and an additional PatientResponsibility nested within.

The original, unmodified PatientResponsibility will still be present at the root of the object.

Services

When creating a Service, include the same clinicalInfo as with the standalone ServiceEligibility to associate with the Service-based estimate.

Limits

Limits include a type, value, period, and metric. Together, these can influence how you communicate eligibility to patients.

Bridge is not currently able to provide a value for the number of times a patient has claimed for a service in this period.

• Type UNKNOWN
  • It is not known whether there is a limit or not
• Type UNLIMITED
  • This plan is known to support an unlimited number of visits
• Type LIMIT, without a value
  • This plan is known to have a limit, but the actual limit value cannot be determined
• Type LIMIT, with a value
  • This plan has a limit, that value is known

Period

The period value indicates the time period over which the limit applies.

• ANNUAL
• BENEFIT_YEAR
• LIFETIME

Metric

The metric value indicates what the limit value represents over the period.

• VISIT
  • This plan allows value visits per period
• UNITS
  • This plan allows value billing units per period