Eligibility

Updated on 19 Mar 2024
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This section of the software is used to help verify the patient's insurance coverage and determine what services are covered by the insurance plan, as well as any co-payments or deductibles that the patient may be responsible for paying.

Steps for viewing eligibility for a patient:

Navigate to Eligibility in the left navigation menu.

Select Provider in dropdown first.
Select Payer in the second dropdown
Eligibility Information in the third dropdown. An Eligibility Request can either be a:
1. Benefit Type (selected in the dropdown)
  or
2. Procedure Code (which can be entered in the field).
  Make sure this is accurate to the kind of service the patient received.
  Important
  Most payers do not respond to the Procedure Code and only respond to the Benefit Type.
Provide as much information as you can about the patient. Policy# or Date of Birth is required to find the patient.
More information may need to be added about the patient in the search, depending on the payer.
Click button to generate results

Example of Eligibility Results

To make it easier to view certain categories, select the Jump to Benefit Category dropdown. From here, selection of categories like Pharmacy, Urgent Care, Physical Therapy, etc. can be selected to jump right to that category without scrolling.

WARNING!

To avoid increasing your organization's Eligibility transaction count, do not repeatedly click on the button while searching for the same patient's payer eligibility information.

Instead, follow these steps:

Click on the Search button.
Enter the patient information in the pop-up window.
In the Filter By dropdown, choose either "My History" (your past queries) or "All History" (all users' past queries).
Select the patient's record that appears on the Eligibility- Live Payer Response Panel to view the previous eligibility queries for that patient.

Populating Eligibility Fields from a Claim

The required search fields can be pre-populated with the patient information from the View/Edit Claims page. This will save time searching and entering the information from a claim.

Steps to check Eligibility from View/Edit Claims page.

Select Check Eligibility in the Other Actions dropdown.
The system will automatically redirect to the Eligibility screen where the Provider, Payer, Eligibility Information and Patient Information will be auto-populated.
Click on the button and notice the eligibility details for this patient will be displayed on the right-hand side.

Get Help

A support ticket can be directly initiated concerning the patient information entered into the eligibility search by clicking the button on the View Eligibility pop-up menu.
Once this button is selected, a ticket will open associated with that patient.
Enter the issue and click the button to send a ticket to the Claim.MD support team.
You can go to Support Tickets to see the status of the associated eligibility ticket.

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