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.


Warning If you do not use the Eligibility verification for 90 days, the service will be locked. Contact Support to reinstate Real-Time Eligibility.


Eligibility will reject if you have hyphens or any symbols in the Patient or Insurance information.

  • Example: Do not use hyphens in the policy number or the Patient's Last Name.
  • If you have a hyphen or ampersand in your Practice name, contact Support.


Check Eligibility from the Patient Dashboard


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

InfoEligibility can also 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 link, it signifies the last time Eligibility was Requested for the DOS.

    • If Verify is gray, hover over the Verify link to receive more information on the issue.

  1. Plus icon: Run Eligibility for a specific date.

  1. Date link: 

    • 06/01/2025: This is the last date that Eligibility was Requested.

    • 06/10/2025: This is the last Date of Service for the Request.

      • Patient Dashboard: Eligibility was checked on 06/01/2025 for DOS 06/10/2025

    • The DOS will be the farthest future date where Eligibility was checked.

      • Example: Eligibility was checked on 06/01/2025 for DOS 06/10/2025.

        • The Verify link was checked again on 06/04/2025.

          • The Date link on the Patient Dashboard will display 06/04/2025 | 06/10/2025.

          • The second date will always be the farthest future date on which Eligibility has been checked.

   

  1. 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 for a specific Date of Service

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


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.
  • Select the Update All link to process all available updates.
  • The ability to copy these fields is controlled by User Permission: Patient > Copy Eligibility Response.


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 to check Eligibility or select 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.

  • This link does not check Eligibility.


Check Eligibility from the Insurance Management Add/Modify Policy Screen

Eligibility can be verified on a specific Patient from the Add/Modify Policy Screen in Insurance Management.

  • After adding the Insurance, select the Save/Verify Eligibility button.
  • If the Eligibility Payer ID is different than the Claims Payer ID, the Eligibility Payer ID can be entered here to verify Eligibility.
  • This Eligibility Payer ID needs to be entered on the Insurance in the Insurance Library to avoid entering it on this screen the next time.


Eligibility History

Eligibility History can be accessed from:

  • Eligibility History Report


Eligibility Responses/Errors

Eligibility Responses and Error Messages can be seen in multiple places throughout the System. Receiving a message other than Eligible may indicate a problem with the Insured/Policy Holder/Policy Information.


Learn More

Insurance Library Eligibility Payer ID

Insurance Eligibility Time Frame

Common Real-Time Eligibility Error Responses

Batch Eligibility Using the Job Scheduler


Internal Use Only

Real-Time Eligibility Internal Settings OR Eligibility Settings

    • Related Articles

    • Eligibility History

      Eligibility History can be accessed from multiple places in the System and can be viewed by Patient and by Batch. Eligibility History Report Reports > Patient panel > Eligibility History button. This report can be used to view the Eligibility checks ...

    • Real-Time Eligibility Responses/Errors

      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. ...

    • Eligibility/Batch Eligibility Overview and Setup

      Eligibility can be checked individually, or the Job Scheduler can be used to run a batch from the Appointments on the Calendar. Real-Time Eligibility Verification Batch Eligibility Using the Job Scheduler To verify Eligibility in a batch, you must be ...

    • Real-Time Claim Status

      *This is a Premium Add-on feature. Common Problems with manually checking Claim Status Challenge of timely follow-up on Insurance Claims that are delayed or have no response from the Payer. A Claim can appear to be Payer Accepted, but the Claim has ...

    • Eligibility Display on the Calendar

      If you use the Eligibility feature, the Calendar view displays the Patient's Insurance Eligibility. If you do not want the Eligibility icon to display on the Calendar, uncheck the Eligibility option. Select the Settings Tab. In the Appointment panel, ...