These are responses that you may receive when doing an Eligibility Check.

• While some responses may indicate a Payer issue.
• Mostly, these indicate a problem with the Insured/Policy Holder Name, address,  Policy Number, or Medicare Advantage Plans.

Eligible with Exceptions, Eligible/Review, & Eligible/Review with Exceptions

• If there are Exceptions, the green check mark is replaced with an orange check mark on the Patient/Encounter Dashboard, Calendar, and on the Response.

• If the Patient/Policy Holder information in the System is different than the Payer's information, it will be returned in Red Font on the Patient's Eligibility Report.
• If the basic Subscriber/Patient information returns different values than the information sent, an Update icon  will display in that area.

• The Update icon can be used to update the information currently in the System.
• When the information has been updated, the Icon color changes to green.

• If changed in error, use the Revert icon to change the information to the previous System value.
• Use the Update All link to process all available updates with one click.
  

Be careful updating the Expiration Date from the Term Date on the report.

• Medicaid may have a Term Date or a Plan End Date at the end of every month; therefore, you would not want to copy the Term Date or Plan End Date to the Expiration Date.

• Some Insurances have a Term Date or a Plan End Date at the end of each year. However, the same Insurance actually renews on the first day of the new year.

• It is best not to update the Expiration Date in this case.

• If the Term or Plan End Date is copied to the Expiration Date, Claims created at the beginning of the next year will not be able to use this Insurance.

• The Expiration Date will need to be removed or a new Insurance Profile created.

Eligible Examples

• Active - Pending Investigation: The Patient is eligible, but is in the second or third month of their premium grace period, and a potential issue (non-payment) is under review for resolution.

• While services may be covered now, the Policyholder must pay their overdue premiums to maintain coverage.

• Contact the Payer for more information.

                        

Eligible With Exceptions Examples

• Different Name: The name on the Insurance may have a middle initial, but there is no middle initial in the System.
• Different Address: The address that the Payer has is different than the one in the System. It could be as simple as Dr vs Drive, or the address could be totally different.
• Different Group Number: The Group number may be blank in the System, or it could be incorrect.

Other or Additional Insurance Plans & Eligible/Review

Other or Additional Insurance Plans may also be found with responses, Eligible with Exceptions.

Eligible/Review may also indicate information that does not match the Payer's.

• The Patient may have another Insurance that may be Primary.

Example 1

The Patient has Medicare and another Group Insurance.

• The Patient is still working and has Group Insurance or they have Insurance under their spouse's Group Insurance.

• Usually, the Insurance that the Patient receives through their own group policy or their spouse's group Insurance is primary, and Medicare is secondary.
• There will be a message in the body of the Eligibility Report.
• In the example below, the Insurance should be Medicare as primary and BCBS as secondary.

Example 2

The Patient has a Medicare Advantage (Replacement/Part C) plan, but the Claim was sent to Medicare. A Message will be in the body of the Eligibility Report with the Name of the Insurance.

Not Eligible

If Not Eligible is returned for the Eligibility Request:

• The Patient may not have that Insurance on that DOS.

• Check with the Patient to determine if they have changed Insurances.

• The Date of Birth may be incorrect.
• It may be under a different Policy Holder.
• The Policy Number by be incorrect.

Not Eligible with Exceptions

A return of Not Eligible with Exceptions may indicate that the Patient has Insurance with the Payer, but not that particular Insurance Policy.

• The Policy Number, Policy Holder, or Address may be different.
• The Patient does not have this Insurance.

• The Policy may have expired.

Unable to Respond at Current Time/Not Found

The following Responses indicate that the Payer's Eligibility Portal cannot be accessed. 

• Unable to Respond at Current Time
• No Connection Available
• Not Found/No Error Message Available

There may be a connection error on the Payers side or an EDI connection error.

• The Payer may be receiving a high volume of requests.
• The Payer/EDI connection may be down.
• Retry your request later.

Not Found with Exceptions

Not Found with Exceptions - Invalid Participant Identification

• The Patient may not have coverage with this Payer.

• Check for New Insurance.

• The Policy Number or Patient Information is incorrect.

• Check to make sure the Policy Number is entered correctly.
• It can be off by only one digit, which will prompt this Error Message.

Not Found/No Error Message Available with Exceptions

This mostly likely means that the Policy Number is incorrect. In the example below, there are some digits in the policy number that are wrong.

Payer Rejected (Invalid) with Exceptions

Invalid/Missing Subscriber/Insured ID: This usually indicates that the Policy Holder ID is incorrect.

• A common error is the Patient is not the Policy Holder, but was sent with the Patient as Policy Holder, Self. Correct and resubmit.

Rejected/Review with Exceptions or Rejected/Review

• Patient Birth Date Does Not Match that for the Patient on the Database.
• Invalid/Missing Subscriber/Insured Name - Patient Birth Date Does Not Match that for the Patient on the Database.

Learn More

Real-Time Eligibility Verification

Eligibility History