Eligibility

The Eligibility tab displays complete eligibility information so you can answer inquiries from members concerning their eligibility for benefits, (medical, dental, and vision). This includes eligibility awarded to individuals from contributions, premium billing, direct pay, COBRA, and eligibility overrides.

Eligibility information bar

From the Eligibility information bar, view the individual's most recent eligibility, eligibility history, or custom eligibility (based on your system setup).

Choose the most recent eligibility, eligibility history, or custom eligibility date with the Recent, All, and Custom filters, at the top of the Eligibility tab. The results display in the Eligibility table.
Select the Summarize check box to switch between a summarized eligibility view and a detailed view. The summarized view combines multiple rows of data in the Benefit Plan, Benefit Plan Name, Plan Type, Plan Type Name, Coverage, and Coverage Name columns to one row.

The last date the individual's eligibility was calculated displays here and you can recalculate the eligibility with the Calculate button. See the Filter to display the individual's most recent eligibility data. .

Note: There's a system administrator control (SAC) to allow a member's eligibility to calculate automatically upon opening the Eligibility tab: <87> Auto calculate eligibility when opening a member. When set to Y, the member's eligibility recalculates when opening in ServiceXG. If N or blank (the default), it won't recalculate on opening.

Eligibility table

The Eligibility table displays the individual's most recent eligibility, eligibility history, or custom eligibility date (based on your system setup).

Eligibility Table Descriptions

Field	Description
Agent	Person or entity that represents the member for benefit coverage.
Begin Date	Date the eligibility coverage began.
Benefit Plan	Benefit plan code associated with the eligibility period. The benefit plan identifies the benefits an individual receives as the result of the individual's association with a subgroup. If you selected the `Summarized` check box, the benefit codes displayed in the row are separated by a comma.
Benefit Plan Name	Name of the benefit plan. If you selected the `Summarized` check box and there are multiple benefit plans codes, this column displays `Multiple`. If there's only one code, the corresponding benefit plan name displays.
Billing Account	The billing account associated with the member.
Country	Individual's country.
Coverage	Coverage code for the eligibility period. The coverage code identifies who is covered by a benefit plan type, for example, individual or family. If you selected the `Summarized` check box, the coverage codes displayed in a row are separated by a comma.
Coverage Name	Name/description of the coverage code. If you selected the `Summarized` check box and there are multiple coverage codes, this column displays `Multiple`. If there's only one code, the corresponding coverage name displays.
Dependent	A dependent number identifies the member and dependents covered by the benefit plan, for example, `0` refers to the member. Dependent numbers `1` and above refer to specific dependents and the dependent number was assigned when the dependent was entered in the system.
Employer	Sponsoring employer's ID.
Employer Name	Name of the sponsoring employer. Note: If the fund is a multi-employer fund, this field will display as `MULTIPLE`.
End Date	Date the eligibility ended (terminated). If there is no end date, the benefit doesn't terminate.
End Date Reason	Description of why the coverage was terminated.
End Date Cd	Code indicating why the coverage was terminated.
Fund	Fund code associated with the contribution or payment. A fund is a legal entity for the contributions and distributions of money.
Fund Name	Name of the fund associated with the contribution or payment. A fund is a legal entity for the contributions and distributions of money.
Network	Network code associated with eligibility in an HMO environment. Note: This data is only available if you have a modified tape load function that allows you to load this data.
Option	The option for the benefit plan associated with the member.
PCP	Primary Care Physician (PCP A physician who serves as a group member's primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services, coordinates and, if required by the plan, authorizes referrals to specialists and hospitals.) code for HMOs (Health Maintenance Organizations). Note: This data is only available if you have a modified tape load function that allows for you to load this data .
Plan Type	Plan type code associated with the individual. A plan type identifies a type of benefit plan, such as medical, dental or vision.
Plan Type Name	Name/description of the plan type such as medical, dental, or vision.
Reason Code	Reason that eligibility started or ended. Extension period ended Subgroup terminated Override terminated Dependent terminated Dependent added Member contributions Member terminated COBRA terminated Direct Pay terminated Self Pay terminated Premium Billing terminated Premium Billing Self Pay terminated Employer terminated
Site	Code associated with the Primary Care Provider (PCP) in a Health Management Organization (HMO). Note: This data is only available if you have a modified tape load function that allows you to load this data.
Status	Individual's eligibility status: `Eligible`—member is eligible for benefits (and has a begin date for eligibility on file). `Ineligible`—member lost eligibility (the member has an eligibility item on file with no begin date).
Subgroup A way to categorize group members into a certain set for benefit plans (e.g. active and retired employees). Subgroup distinctions are only used in Claims, COBRA and Eligibility.	User-defined code representing a grouping of benefits associated with the individual's eligibility.
Subgroup Name	Name of the subgroup.

You can switch between the most recent eligibility, eligibility history, or custom eligibility with the Recent, All, and Custom filter options at the top left of the Eligibility tab.

The Eligibility table is read-only so you can't add, update, or delete the information, but you can sort, filter, and group data, and create and save a different view A custom-defined representation of the data. of the data that display. Refer to Common features (for standard table features) and Views for details.

Below the Eligibility table is an expandable and collapsible panel that displays the Detail tab and the Matrix tab. These tabs display more details about the selected row of eligibility information.

Detail tab

Detail Tab Field Descriptions

Field	Description
Dependent Number	A dependent number identifies the member and dependents covered by the benefit plan, for example, 0 refers to the member. Dependent numbers 1 and above refer to specific dependents and the dependent number was assigned when the dependent was entered in the system.
Dependent Name	Name of the individual.
ID	Individual's Social Security Number.
Relation Description	Relationship to the member, for example, member, spouse or dependent.
Gender Description	Individual's gender (male, female or unknown).
Birth date	Individual's birth date.
Age	Individual's current age.
Start Date	Individual's most current start date with the membership. Note: The dependent can't have eligibility before this date.
Start Reason Description	Status code associated with the start date
Term Date	Termination date for individual's benefit plan.
Term Reason Description	Textual description of reason for termination of eligibility.
Medicare Type	Code that identifies the type of medicare coverage.
Medicare Type Description	The reason the individual is eligible for Medicare coverage: `0—Other`, `1—Over Age 65`, `2—Disabled`, or `3—End Stage Renal`.
Medicare Effective	Date the individual is eligible for Medicare.
Medicare Expiration	Last date of the individual's Medicare coverage.
Gender	Code that indicates the individual's gender.
Relation	Code that indicates the individual's relationship to the member.
Start Reason	Code for reason coverage was begun.
Term Reason	Code for reason coverage was terminated.

The Detail tab table is read-only. You can't add, update, or delete the eligibility information. Also, you can't choose the data that displays in the table, but you can perform some standard table functions like moving columns around, and sorting and printing the data. To print or export the data from the table, click gear icon and select the appropriate option. See Common features for more information on printing and exporting data from a table.

Matrix tab

The Matrix table displays the eligibility being calculated and includes the rules, work period, and other details. The matrix header contains the Fund and Display all benefit plans check box. The Fund displays for the selected member's eligibility. If the member is ineligible, no fund displays. The Display all benefit plans check box lets you view all benefit plans.

The monthly eligibility information can help you troubleshoot or respond to discrepancies in a member's eligibility. For example, you might have calculated that a member should have eligibility through December, but the record only shows eligibility through November. You can walk through the eligibility month-by-month to check for discrepancies.

Matrix Tab Field Descriptions

Field	Description
Display all benefit plans	Displays matrix tab information for the individual’s benefit plans.
Accum Hrs Self-Pay	Accumulated self-pay hours. Individuals who have insufficient hours worked for contributions pay an amount (self-pay) to retain eligibility. Depending on the plan, this amount can be a flat rate or a base rate that is multiplied by the number of hours needed.
Bank	Number of hours/dollars banked (if the eligibility rules allow for banking of hours or dollars in excess of the required hours/dollars). These hours/dollars can be used later to obtain eligibility.
Benefit Plan	Benefit plan code associated with the period. The benefit plan code identifies a specific set of benefits packaged together.
Benefit Plan Description	Description of the benefit plan code.
Benefit Plan Type	Benefit play type associated with the individual's eligibility.
Contract Type	Contract code.
Contribution Rate	Rate used to calculate the individual's contributions.
Coverage	Coverage code associated with the period. The coverage code identifies who is covered by the benefit plan, for example, individual or family.
Coverage Desc	Description of the coverage code.
Criteria Type	Criteria used in the eligibility schedule Defines parameters for Apps, contracts, status', pay, benefits, rules, etc.., for example, group, contract, or employer.
Criteria Dol	Dollar amount by criteria type used in the eligibility schedule.
Criteria Hrs	Number of hours by criteria type used in the eligibility schedule.
Dollars	Total dollar amount contributed on behalf of the member for the fund, for the work period. This amount is the rate multiplied by the quantity.
Excess Bank	Number of hours/dollars over the maximum number of hours/dollars banked.
Hour Non Re-Use	Hours which have been marked for non re-use.
Hours	Number of hours reported for the fund, for the period.
Hours-No Self Hrs	Quantity of hours exceeding any self-pay quantity; typically refers to hours but can be days or wages.
Period	Period in which contributions are posted and eligibility is given according to the rules of the fund which are defined in the eligibility schedule. When examining contributions in the eligibility matrix, this is the work period. When examining the eligibility status, this is considered the eligibility period.
Self-Pay Cnt	Amount the individual can self pay to become eligible for benefits.
Self-Pay Due	Amount of self pay dollars due. This is the self pay contributions minus the self pay amount paid.
Self-Pay Paid	Amount of self-pay money paid to maintain coverage.
Self-Pay Part Rfnd	Amount of a partial refund of self-pay money. This will occur if different rules are used to buy eligibility in different months within the same period (eligibility period).
Self-Pay Amount	Contribution amount paid by the individual to obtain eligibility.
Self-Pay Refund	Self-pay refund amount.
Status	Eligibility status for the period (the period when looking at the status is the eligibility period.) If a Y is in the first position, the individual is eligible for the benefit aligned with this status and period; any other character designates ineligibility.
Subgroup	User-defined code representing a benefit grouping associated with the individual's eligibility for the benefit period’s plan and coverage.

The Matrix table is read-only so you can't add, update, or delete the eligibility information but, you can choose the data that displays as well as sort, filter, and group data, and create and save a different data view. Refer to the Common features (for standard table features) and Views topics for more details.

For example, the matrix displays all historical work periods with the earliest at the top, but you can use the filter to view more recent work periods.

You can apply filters to specific columns by selecting the dropdown arrow . Filters can: Contain, Equal, Not Equal, Start with, or End with alphanumeric data. Be Equal, Not Equal, Greater, or Less than a selected Received date. Apply additional operators such as Or and And for more refinement.

Select the filter and choose the information to filter by. For example, select and choose the work periods to include or exclude.

Matrix View Designer

The eligibility matrix contains a view designer that lets you control which work periods display in the beginning of the table. You can either view a member's first eligible work period or the current period plus a defined number of lookback periods.

Note: The number of lookback periods you can view depends on the setting of ELG SAC <103> - ELG Matrix Display Period Lookback. This SAC defines the number of work periods to look back when the eligibility matrix view designer is configured to use the Current Period plus lookback. Contact your administrator for more information.

For example, the default setting is to view the historical work periods. If the member's eligibility dates back to October 2002, the work period for 200210 would display first in the matrix.

However, from the view designer, you can change this setting to display the current work period and a specified number of lookback work periods. If the current period is July 2024 (202407), and you set the ELG Matrix Display Period Lookback SAC to 10, the matrix would set the focus of the display to the 10th month prior to the current July work period. All work periods remain in the display you can scroll as needed to review other periods.

Select from the Matrix tab.
Click Add view or Edit view.
From the View Designer window, select the Current Period plus defined lookback (X months) check box to have the matrix table display the current period plus the defined lookback. In this example, the lookback was set to 10 months.

Finish editing your view and click to save.
The Matrix table now displays the current period plus the lookback months. If a member doesn't have enough history to display the number of lookback months, the table displays as much information as possible.

To return to viewing the member's first period, open the View Designer and deselect Current Period plus defined lookback.

Premium Billing Matrix tab

On the Premium Billing Matrix tab, you can view member eligibility calculations and their employment status changes.

Note: You might not have permission to view this tab. Contact your administrator for access.

Premium Billing Matrix Tab Field Descriptions

Field	Description
Period	The current billing period.
Period From	The period from date.
Period Thru	The period thru date.
Parent	Indicates if there's an associated parent employment status for the period.
Employment Status	The member's employment status for the period.
Billed	Indicates if the period was billed. Y—Yes.

The Premium Billing Matrix tab is read-only. You can't add, update, or delete the eligibility information, but you can sort and filter the information that displays. Refer to the Common features topic for standard table features and the topic to change the data columns in the view A custom-defined representation of the data..

To print or export the data from the table, click gear icon and select the appropriate option. See Common features for more information on printing and exporting data from a table.