Real Time Eligibility

We receive what the payer sends us. Results should be reviewed and the user needs manually update insurance policy if the results show this in red. We do auto populate the plan/policy based on the payer's response.

If you are using the calendar, we suggest use of the job scheduler. Set it up to run eligibility before the patient presents for their visit. Job Scheduler > Batch Eligibility

To review results for specific days on the calendar (if using) -Eligibility CAQ - custom appointment query

Verification is available from the:
Patient Dashboard > 'Active Policies' section, the link displays next to each insurance where real-time verification is available.

Appointment page > 'Eligibility' link shows the full history or to check 'on the fly' > Click [Check Eligibility]. If you have a green check mark on this button, the patient has eligible insurance, click the hyperlink 'Eligibility' to review the results

How to read and respond to Eligibility results

Review Dependent/Subscriber information, note items in RED, should be manually updated- especially Policy

Address listed is FROM the payer * useful for DME
Policy Effective/End date where available OR when viewing 'history' the Requested Date

2. Use the Search drop-down to filter by specialty or for general coverage '*Health Benefits Plan'

Pay special attention to: (A)Copay, (B) Deductible - remaining or left to pay

3. For Medicare / Medicaid, look to the 'other or additional payer' area

In this screenshot, Medicare informs us Humana is the medicare replacement, therefore the insurance profile should be: Humana > Patient responsibility, not Medicare Primary

How can I tell if an insurance is a Replacement Product or if Medicare is secondary?

Replacement product:

In this example under group number Blue Cross indicates this Policy is an 'Advantage' plan

The Medicare results will list Blue Cross in the 'other or additional payer' area

In this example, under the 'active coverage', Humana reflects 'Medicare PPO'

The Medicare results will list Humana in the 'other or additional payer' area

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Medicare is Secondary:
Look under 'Other or Additional Payer', if there is a reason listed under 'Insurance Type Code', then Medicare is Secondary

The user will manually add this to the Medicare Policy

How do I add eligibility request from phone calls or direct contact to the payer?

There are times a payer does not provide us with real time eligibility results. In those cases we may call or log on to the Insurance portal.

Click the Eligibility link in the 'Active Policy' section of the patient dashboard, to review the full history of Eligibility checks and/or [ADD] manually retrieved results.
Click [ADD] for manually retrieved results - such as a call to the Insurance or log on to their portal
Choose which Insurance, what status
[SAVE]

Is there a way to view historic eligibility results?

From the Patient Dashboard > in the 'Active Policy' section >' Click Eligibility'
From the Appointment screen > Click the hyperlink 'Eligibility'

This action opens the 'Eligibility Request History' page

Use filters for: who it was run by, when, for what DOS/Insurance, eligibility status at the time
Click [View] to generate the full original request for review

These requests are retained for one calendar year

How do I check other Dates of Service other than today?

From the Patient Dashboard, a ‘+’ is next to the ‘Check’ eligibility link. Click the +, a popup allows you to choose the DOS to verify

Eligibility verification can also be done from the Encounter Dashboard. This will automatically verify the DOS of the Encounter.

What if the Eligibility Payer ID is different than the one listed in the insurance library?

To have the system verify eligibility against a different Payer than the one designated for claims, simply add that Payer ID to this field. If the field is left blank, the system will check the Eligibility for the Payer designated in the Insurance Library.

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