Eligibility checks

You can run real-time eligibility checks to a verify patient's insurance coverage and get information about a patient's insurance coverage status, co-pays, deductibles, etc..

Prerequisites

Part 1: Set up RCM integration (EMR)

In order to run eligibility checks, you need to set up the RCM integration

Follow the instructions here to set up your RCM integration.

Steps

Step 1: Run an eligibility check (EMR)

To run an eligibility check:

• Go to the EMR (e.g. emr.avonhealth.com)
• Click on the hamburger menu on the top left corner > Click Patients > Click on "View chart" for the appropriate patient and then either:
  • Click the "Add" button and select "Eligibility Check" from the dropdown OR
  • Click "Eligibility Checks" from the top bar and click "Run an eligibility check"
• The eligibility check modal will pop up. In it, select:
  • Patient: Patient name. This should be pre-selected.
  • Requesting provider: The member who is requesting th eligibility check. This member have a valid NPI set in the platform.
  • Insurance policy: Which of the patient's insurance policies you want to run the eligibility check on. The patient's insurance policies are pulled from the list of insurance policies set on the patient's profile.
• Click "Run eligibility check"

Step 2: View eligibility checks (EMR)

• Go to the EMR (e.g. emr.avonhealth.com)
• Click on the hamburger menu on the top left corner > Click Patients > Click on "View chart" for the appropriate patient and then either:
  • Find the desired eligibility check card in overall patient chart OR
  • Click "Eligibility Checks" on the top bar and find the desired eligibility check card
• Click on the eligibility check card

Step 3: Eligibility check response (EMR)

The eligibility check response contains the following information:

• Patient: The patient's name, MRN, and date of birth.
• Insurance Policy: The insurance policy that we ran the eligibility check on, including information on the policy's name, plan name, policyholder, member ID, and group number.
• Benefits Information: This covers:
  • Active Coverage: Which services have active coverage, such as:
    • Emergency Services
    • Hospital - Outpatient
    • Medical Care, Mental Health, Urgent Care, Chiropractic, Hospital, Hospital - Inpatient, Professional (Physician) Visit - Office
    • Emergency Services
    • Health Benefit Plan Coverage
    • Other Medical
  • Coinsurance: What the coinsurance is for different service types, whether the coverage is individual or family, what the benefit amount is and on what time scale
    • For example, a particular policy may have emergency services (service type) for an individual (coverage level) have a co-insurance (benefit) of 15% (benefit amount) per day (time qualifier)
  • Copayment: What the copayment is for different service types, whether the coverage is individual or family, what the benefit amount is and on what time scale
    • For example, a particular policy may have emergency services (service type) for an individual (coverage level) have a co-payment (benefit) of $75 (benefit amount) per day (time qualifier)
  • Deductible: What the deductible is for different service types, whether the coverage is individual or family, what the benefit amount is and on what time scale. It also contains information about how much of the deductible has been spent to date this year and how much is remaining.
    • For example, a particular policy may have emergency services (service type) for a family (coverage level) have a deductible (benefit) of $0 (benefit amount) per calendar year (time qualifier)
  • Out of pocket (stop loss): What the out of pocket maximum is for the health plan, whether the coverage is individual or family, what the benefit amount is and on what time scale. It also contains information about how much of the deductible has been spent to date this year and how much is remaining.
    • For example, a particular policy may have the out of pocket maximum (benefit) for an individual (coverage level) be $1300 (benefit amount) per calendar year (time qualifier)
• Full Response: The full, unparsed 271 file response received from the payer.