How to Read the Eligibility Report

How to Read the Eligibility Report

Tips for Reading the Eligibility Report

  1. Use the Service dropdown list to filter by specialty or for general coverage (Health Benefits Plan Coverage).

Deductible/Copay/In or Out of Network

  1. Deductible: Remaining or left to pay

  2. Copay

  3. In/Out of Network


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 will indicate 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.



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.

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