Run an Eligibility Check

Eligibility Checks may be run at any time to check the status of a Patient’s insurance. This topic provides the necessary steps to run an Eligibility Check on a single Patient (ad-hoc), or as part of an Eligibility Batch.

Enable the Eligibility Check feature from Admin > Contract Setup. Refer to the Eligibility Check Setup for instructions.

  1. Go to Patient > Search Patient > Eligibility Check.

  2. The Patient Eligibility Check search screen appears. The top part of the screen provides a search function allowing one to search for all Eligibility Checks made for a Patient, whether ad-hoc or as part of a larger batch. Complete the search filters in the Patient Eligibility Check section.

    The Check Now (bottom) function allows you to run an immediate eligibility check for the Patient.

    Patient Eligibility Check Page

    • Select the From Date to set a date range for the check.

    • Select the To Date to set a date range for the check.

    • Select the type of check to run: All, Ad Hoc, or Automated Batch.

    • Select a specific Contract or All Patient Contracts to check.

    • Enter the Alt Patient ID assigned to the Patient by the Contract/Payer.

    • Choose to see All the results, or only specific ones such as Denied or Eligible.

    • Select Contract and click the Check Now button to run an ad-hoc check on the Patient immediately.

  3. Search results display the selected parameters.

    Patient Eligibility Check Search Results

The Eligibility Batch Review feature allows you to search for all Eligibility Check Batches using the available search filters. Follow the steps below to run a batch review.

  1. Go to Patient > Eligibility Batch Review.

  2. Complete the following fields and select Search to filter for the Eligibility Batches.

    Eligibility Batch Review Search

    • Office(s): Select from this dropdown to search for Eligibility Batches associated with specific Offices.

    • Contract: Filters search results so Patients under a certain Contract display.

    • From/To Date: Specify date parameters to run the batch.

    • Batch Type: Refers to how the Eligibility Check was executed. Select Ad-hoc (by the user), Automated Batch (as determined in Setup), or All (show all).

    • Batch Status: Select the status value of an Eligibility Check: All, Pending, Submitted, or Reviewed.

  3. Search results display the selected parameters. Select the batch(es) to review. Once selected, the Export Selected Batches button becomes available.

    Eligibility Batch Review Search Reults

    • Click the Export Selected Batches button and select from the list of Batch types to open an Excel file with the selected batch details.

    • Click the link under the Total Patients Checked, Denied Patients, or Elig. On Diff. Contract columns to open an Excel file with the individual batch details.

      If results display under the Elig. On Diff. Contract column, this means the patient is eligible but not for the contract name you searched for. Verify all applicable Contract names are added to the Contract Submission Name field on the Eligibility Check feature.

    • Click the Batch Number link to open the Eligibility Batch Details window.

      The Eligibility Batch Details window displays all records checked within the batch. Records with the Result Code of Check Details or Denied indicate more information is needed or eligibility is denied.

      Eligibility Batch Review - Results Code

The Eligibility Check Review feature under Member > Eligibility Check Review allows you to review patient eligibility.

Eligibility Check Review

Enter search criteria in the fields to Filter results by:

Eligibility Check Review Check Status

  • Date Range

  • Eligibility Check Status

  • LME/PHP

  • Medicaid Number

  • Member

  • Member Status

  • Office

  • Review Status

To check the Eligibility Status of a Patient,

  1. Go to Member > Eligibility Check Review.

    Eligibility Check Review

  2. Complete search fields, and then select Search.

    Eligibility Check Review Check Status

  3. Check the Member Eligibility from the search results.

    • The Check Status column displays the eligibility status.

    • The Additional Information column contains more information around the eligibility check results.

  4. Fix issues listed in the Additional Information column and then re-run the eligibility using the Eligibility Check feature under Member > Search Member > Eligibility Check.

From the Actions column you can:

Patient Eligibility Check Action Column options

  • View Detailed Review Results

  • Set Member Status to Hold or Active

  • Mark as Reviewed

  • View Member Details

  • View History

Quickly apply an action to multiple entries on the Eligibility Checks results using the Bulk Actions button.

To apply the Bulk Action, select the checkbox beside the desired Members, select the Bulk Actions dropdown, and then choose an option from the bulk actions to apply to the chosen entries.

Bulk Actions on the Eligibility Check Review feature

Export the Eligibility Checks results in a CSV, Excel, or PDF format.

To export Eligibility Checks results, select the Export dropdown, and then choose an option from the menu.

Export on the Eligibility Check Review feature

Eligibility Check Review Check Status

The Latest Check button displays the latest Eligibility Check results.

The All Checks button displays all Eligibility Check results.