Insurance Coverage 26.04

The features below are available with this release.

Highlights

• A new AI agent now compares data from the visit with information from the payer to determine which benefits are to be applied the encounter.
• Logic now is included to determine the correct health plan based on attributes from the claim after you select the payer.

Solution Change Details

Solution Change	Description and UI Impact	Reference Materials	Validation Guidelines	Implementation and Maintenance Impact
Eligibility Verification AI Agent - CDAF-52940	The Eligibility Verification (EV) agent now is available. The EV agent delivers an intelligent, unified eligibility verification engine, designed for real-time automation and integration across Oracle Health applications. The EV agent can identify patient coverage for accurate billing and provider reimbursement. UI Impact: None	None	No validation testing is provided because the solution change contains updates to system processes that support front-end functionality and that cannot be tested directly. This solution change is associated with a solution change for the front-end functionality, which includes the certification guidelines necessary to test the functionality. As part of your regression testing, ensure that your system is working as expected.	Implementation Impact: None Maintenance Impact: None
Additional Payer Detection - CDAF-69916	You now can identify other payers that were not identified on the encounter. Payers may have previously been unidentified due to lack of patient awareness of another health plan, error in entering insurance information, and so on. UI Impact: None	None	No validation testing is provided because the solution change contains updates to system processes that support front-end functionality and that cannot be tested directly. This solution change is associated with a solution change for the front-end functionality, which includes the certification guidelines necessary to test the functionality. As part of your regression testing, ensure that your system is working as expected.	Implementation Impact: None Maintenance Impact: None
Service Type (AI) and Network Type (Non-AI) Identification - CDAF-69928 and CDAF-69927	To determine the copay amount and benefit summary, you now can use the EV agent as deterministic logic. The EV agent can help identify the specific service type relevant to the encounter and corresponding network type. UI Impact: None	None	No validation testing is provided because the solution change contains updates to system processes that support front-end functionality and that cannot be tested directly. This solution change is associated with a solution change for the front-end functionality, which includes the certification guidelines necessary to test the functionality. As part of your regression testing, ensure that your system is working as expected.	Implementation Impact: None Maintenance Impact: None
Benefit Summary Extraction - CDAF-69923	To determine encounter specific benefits, you now can use the EV agent to view all benefits associated to each selected service type and network type. UI Impact: None	None	No validation testing is provided because the solution change contains updates to system processes that support front-end functionality and that cannot be tested directly. This solution change is associated with a solution change for the front-end functionality, which includes the certification guidelines necessary to test the functionality. As part of your regression testing, ensure that your system is working as expected.	Implementation Impact: None Maintenance Impact: None
Financial Allocation Prioritization - CDAF-74351	To collect the appropriate copay at the time of service or before the service, you now can use the EV agent to determine the primary health plan and expected copay. UI Impact: None	None	No validation testing is provided because the solution change contains updates to system processes that support front-end functionality and that cannot be tested directly. This solution change is associated with a solution change for the front-end functionality, which includes the certification guidelines necessary to test the functionality. As part of your regression testing, ensure that your system is working as expected.	Implementation Impact: None Maintenance Impact: None