Real-Time Eligibility Verification

Real-Time Eligibility Verification

Insurance Eligibility can be checked from various locations in the System. The Eligibility Payer ID and Eligibility Time Frame is setup in the Insurance Library.

Check Eligibility from the Patient Dashboard

If the Claims Payer ID does not match the Eligibility Payer ID, the Eligibility Payer ID must be selected. If it is not available in the Clearinghouse Payer List, Eligibility cannot be verified for that Payer.

Eligibility can be checked from the Active Policies panel on the Patient Dashboard.
  1. Verify link: Use the Verify link to run a new Verification check.
  • If there is a Date, it signifies the last time Eligibility run.
  • If the Verify link is gray, hover over it to receive more information on the issue.
  1. Plus icon: Run Eligibility for a specific date.
  2. Date link: This is the last date that Eligibility was checked.
  3. Green Check mark: Indicates that the Patient was Eligible on the Date that is displayed.
  • Eligible with Exceptions: Orange check mark and needs to be reviewed.
  • Eligible/Review or Eligible/Review with Exceptions:
    • May have a green check mark but need to be reviewed.
    • These are usually issues with Medicare where the Patient has Medicare Part A but not Part B.
  • Orange Question Mark: Could not check Eligibility
  • Red X: Not Eligible.

            


Eligibility Results Report

  • If the basic Subscriber/Patient information returns different values than the information that was sent to check Eligibility, an Update icon will display on the Response.
  • Example: Address in the PM System is 123 ABC St, Anywhere, Ohio 44324, but the Eligibility Report returns 1234 ABC St, Anywhere, Ohio 44324.
  • If you use the Update icon to update the information currently in the System, the Icon color changes to green.
  • If changed in error, use the Revert icon to change the information back to the previous System value.
  • Use the Update All link to process all available updates with one click.




Other or Additional Insurance Plans

If the Patient has Other or Additional Insurance, it will be noted under the Status on the Eligibility Report.

  • This usually pertains to Medicare Patients that have a Medicare Advantage Plan or have another Primary or Secondary Insurance.



Eligibility for a specific Date of Service

  • Select the Plus icon  to choose a Date of Service.
  • Enter a Date of Service.
  • Select Verify Eligibility [F2].



Eligibility History

Eligibility History can also be accessed from the Reports Dashboard (Reports > Patient panel > Eligibility History).
  • Under the Active Policies panel on the Patient Dashboard, click Eligibility History.



  • Use the filters to view details of who requested the Eligibility check and when it was requested.



  • Click View to see the Eligibility Verification Report.



Check Eligibility from the Appointment

Check Eligibility during the add Appointment Process

  1. Select an Appointment Slot.
  2. Enter the Appointment Information.
  3. Select the Save/Manage button.
  4. Hover over the Eligibility button to see previous Eligibility checks.
  5. Select the Eligibility button to check Eligibility.
  6. Select the Verify link or the Plus icon to check Eligibility for a specific date.

Eligibility Button on the Patient's Appointment Screen

The Eligibility button on the Patient's Appointment screen should only be used to run a New Verification check, not to view history.
  • Hover over the button to view all Active Insurances and Eligibility Status (if it has been verified previously).



  • Hover over the icon on the Eligibility button to see the meaning of the status. Hover over the Eligibility button to see more detail.
  • Green check mark: Eligible  

  • Orange question mark:
    • Eligibility Status Unknown   

  • Orange check mark: Eligible with Exceptions  

  • Red X: Not Eligible

  • N/A: Policy

Select the Eligibility link to display all historical Eligibility Verification results.

  1. This link does not check Eligibility.


Check Eligibility from the Insurance Management Add/Modify Policy Screen


Eligibility can be verified from the Add/Modify Policy Screen in Insurance Management.
  1. After adding the Insurance, select the Save/Verify Eligibility button.
  2. If the Eligibility Payer ID is different than the Claims Payer ID, the Eligibility Payer ID can be entered here to verify Eligibility.
    1. This Eligibility Payer ID needs to be entered on the Insurance in the Insurance Library to avoid entering it on this screen next time.

Learn More

  1. Insurance Library Eligibility Payer ID

  2. Insurance Eligibility Time Frame

  3. Common Real-Time Eligibility Error Responses

  4. Batch Eligibility Using the Job Scheduler




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