Tips for Reading the Eligibility Report

Items in Red are potentially incorrect and can be updated from this screen. Learn More: Real-Time Eligibility Responses/Errors

Status Panel

1. Eligible
   
2. Eligible with Exceptions: Some of the information in the System may be wrong, such as DOB, Policy Holder, Address, etc.
   
3. Eligible/Review with Exceptions
   
4. Not Eligible: Patient does not have this Insurance with the information that was provided at the time of the Eligibility check.
5. Not Eligible with Exceptions: Patient probably had this Insurance, but it is no longer active. Get new Insurance information from the Patient.
6. Payer Rejected (Invalid): Invalid/Missing Subscriber/Insured ID or Name. This could be something as simple as a middle initial or a mistyped Policy Number or a different Policy Number for the Policy Holder, such as having an 01 or 02 at the end of the number.
   

Eligibility Request Panel

1. Patient Name
2. DOB: The Date of Birth must reflect the same DOB in the Payer's System.
3. Policy Number: Patient's Policy number, which could be slightly different than the Policy Holder's number.
4. Type
5. DOS

Subscriber Panel

1. Message Banner: If there is something that appears to be wrong, a message may display.
2. Subscriber's Name: The Subscriber may be different than the Patient and must match the information in the Payer's system.
3. Current Policy Holder: Shows the relationship to the Patient
4. Address: Only shows if the Policy Holder is different than the Patient
5. Policy Number/Payer Name: This is the Policy Holder's (Subscriber's) number, which may be slightly different than the Patient's Policy Number.
6. Group Number/Group Name: If this field is blank in Insurance Management or if the Payer does not return any Group information, it will display "No Group Information Received". The Payer may also return information that you do not have in the PM System and can be used to update the information.
7. Request Date: Date Eligibility was verified.
   

Default Insurance Profile

This shows the Default Insurance Profile that is in the Insurance Management along with the Date of Service (DOS), Requested Date, the Role (Primary, Secondary, or Tertiary), and the Most Recent Eligibility Status.

Eligibility Panel

Use the Service and Type dropdown list to filter by specialty or for general coverage (Health Benefits Plan Coverage) and for Copay, Co-Insurance, etc.

The Eligibility Panel is divided into categories. If All is selected, all categories will display. Selecting filters from the dropdown menus will limit the scope of Eligibility.

1. Service: Filter by
   
1. Leave as All, select Health Benefit Plan Coverage for general information or select a Specialty.
   

1. Type: Filter for specific information, such as:
   
1. All
2. Active Coverage
3. Co-Insurance
4. Co-Payment
5. Deductible
6. Non-Covered
7. Primary Care Provider
   

Deductible/Copay/Co-Insurance

In-Network and Out-of-Network: The Eligibility results do not show whether the Provider/Clinic is In or Out-of-Network, but it does indicate if Out-of-Network coverage is available to the Patient.

1. Deductible Amount and Remaining Amount
   

1. Copay and Co-Insurance 
   

Advantage/Replacement Plans

1. Medicare or Medicaid: Advantage/Replacement plan information is located in the Other or Additional Payer area.  For example: In the figure below, the Medicare Eligibility Report shows that Humana is a Medicare replacement.
   
1. The Insurance Profile should be Humana with no secondary.
   
2. Medicare should not be in the profile.
   

1. In the next example, the BCBS Advantage Plan is notated in the Group Number/Group Name field.
   
1. The Medicare Eligibility Report will list BCBS in the Other or Additional Payer panel.
   
2. The Insurance Profile should be BCBS Advantage Plan with no secondary.
   
3. Medicare should not be in the Profile.
   

Medicare is Secondary

In the Other or Additional Payer panel:

1. The Insurance Type Code indicates that Medicare is Secondary.
2. The MSP reason Medicare Secondary Reason) is given and must be on secondary Medicare policy in the Insurance Profile.
1. The MSP reason will auto-populate when Eligibility is checked.
   

Another Example where Medicare is Secondary

The Patient is covered under the spouse's group Insurance, which is Primary. The Patient also has Medicare, which should be Secondary.

1. Eligibility Results
   

Plan and Product

If the Plan and Product are available in the Eligibility Report, it will auto-populate those fields on the Add/Modify Policy screen.

1. If a Patient has both Part A and B, the more applicable Plan will show.
   

Learn More

Batch Eligibility Overview

Real-Time Eligibility Verification

Eligibility History

Real-Time Eligibility Responses/Errors

Manually Add Eligibility Responses

Insurance Library Eligibility Payer ID

Insurance Eligibility Time Frame

Batch Eligibility Using the Job Scheduler