Eligibility reports help you describe the insurance benefits provided to clients by their insurance company. It helps you verify a client's insurance coverage, determine covered services, and identify any co-payments or deductibles the client may owe.
Note: Electronic eligibility reports are available for workspaces with an active subscription in the United States. Eligibility reports are a pay-as-you-go feature, and usage is tracked for eligibility requests.
In this guide, you will learn how to:
Prerequisites
To run electronic eligibility reports, you must first:
Import electronic payers into your workspace.
Be credentialed and enrolled with the payer.
Have added a client insurance policy
Request an eligibility report
To request an eligibility report, do the following:
Go to Clients.
Select the specific client to open their profile.
Navigate to the 'Insurance' tab.
Find the client's insurance policy in the 'Insurance policies' panel.
Ensure that the minimum details are set on their policy and related dates. This includes:
The policy member ID
The contact details (first & last name and date of birth)
The policy holder (including their first & last name and date of birth)
Some payers may require additional details.
Hover over the policy and click the 'Eligibility request' hover action.
The request eligibility report sidebar will open.
Change the billing profile if you have enrolled with a different NPI and/or tax number. It must match the billing details enrolled with the Payer.
Choose the client and policy you want to verify
Choose the benefit code or procedure code to request benefits for.
Click 'Check eligibility'.
Notes:
If the request eligibility actions are not available
Make sure you're on a paid subscription.
Check that the policy is linked to a connected payer and that they support electronic eligibility transactions.
Manually added payers are not supported
Benefit code 30 is the general health benefit category.
It includes general benefits and plan details, making it a good default to request.
Many payers do not support eligibility requests for specific procedure codes, or only allow requesting one at a time.
Requesting for specific benefit code instead is much more reliable.
If you do not get a valid eligibility report back
Check that the client and policy holder profiles are complete. First & last name, date of birth at a minimum.
Some insurance payers also require the client's and/or policyholder's sex to match their benefits.
Check your billing profile matches the details on file with the payer.
Try again with a single benefit code or procedure codes.
View a client's eligibility report
After eligibility reports have been requested, the report can be viewed from the client's insurance dashboard. You can do this by doing the following steps:
Go to Clients.
Select the specific client to open their profile.
Navigate to the 'Insurance' tab.
Look for the client's insurance policy in the 'Insurance policies' panel.
The latest eligibility report is shown under the insurance policy.
Click 'View report'.
The report shows all requested benefits related to the client’s insurance policy.
At the top of the report, review the 'Policy details panel' for an overview of the client’s policy.
You can also navigate the benefits category by clicking the 'Benefits list' in the left-hand navigation to jump to specific categories.
View a client's eligibility history
To view a client's eligibility history:
Go to Clients.
Select the specific client to open their profile.
Navigate to the 'Insurance' tab.
Look for the client's insurance policy in the 'Insurance policies' panel.
Click the 'Recent reports' tab in the left-hand navigation
A list of recent eligibility reports is shown.
Click any eligibility report to load the report and view coverage from that date.
View all eligibility reports
A list of all eligibility reports can be found in the Insurance settings. This is useful for auditing purposes. To do this:
Go to the Settings page.
Select 'Insurance' from the main navigation.
Click 'Eligibility' in the insurance menu.
A list of all eligibility reports is shown.
You can apply filters to find particular reports.
View monthly eligibility usage
Eligibility reports are a paid add-on. To view your monthly eligibility usage:
Click Settings.
Go to Workspace Settings.
Select 'Subscriptions' in the workspace menu.
Scroll down to the Insurance usage panel. The current usage period and eligibility usage are shown under Insurance eligibility checks.
Note: Eligibility usage is billed monthly, even on annual plans.
Our team will be able to answer any other questions you may have. Just reply via messenger through the Help channel in your workspace.