Check Patient's Insurance Eligibility (RCM)

Eligibility verification is the process of checking a patient’s active coverage with the insurance company to verify information such as coverage, copays, deductibles, coinsurance, and other benefits.

Patient’s insurance information can change at any time, potentially causing claim rejection or denial, so it's important to verify patient’s coverage before every appointment and before submitting claims. This verification helps to ensure that the patient's insurance information is accurate and up-to-date, reducing the risk of billing errors or providing services that are not covered by the patient's insurance plan.

In this article you'll learn about:

• How to activate eligibility checks
• How to submit eligibility checks
• How to view eligibility check results
  
  • How to view the original response from the payer
  • Contacting the payer to verify additional details
• How to use eligibility history
• How to interpret eligibility check errors 
• How to view the number of submitted checks per practice

How to activate eligibility checks

The Eligibility Check feature is provided at an additional cost - please reach out to your Customer Success Manager or shoot an email at support@remedly.com for pricing information.

Once contracted to start using this feature, you'll need to enroll with each payer for submitting eligibility checks which might take some extra time. Kindly note that some payers do not provide real-time eligibility results.

How to submit eligibility checks

Eligibility checks can be done from inside the insurance policy of each patient. In order to submit an eligibility check, follow the steps below:

1. Choose the patient and the insurance policy you would like to submit an eligibility check for:

If you're in the EHR:

a) Open the patient's profile:

b) In the Insurance tab, select the Insurance policy you would like to submit an eligibility check for:

If you're in the RCM:

a) Open the patient's profile:

b) In the Insurance tab, select the Insurance Policy you would like to submit an eligibility check for:

2. Under More Actions, select Check Eligibility or Check Eligibility for Insurance Plan Company:

4. Complete the additional input fields as requested: select a Provider with NPI, and the Service Date if required. Hit Check Eligibility:

5. You'll see a notification that eligibility check has started. The status (processing...) will show up in the Eligibility preview tab:

6. In case the payer doesn't support real-time eligibility checks, you'll also see a notification clarifying that:

7. In case you select the option to Check Eligibility for Insurance Plan Company, yet the Insurance Plan Company information hasn't been filled out, you'll see an error indicating that you need to add the information to be able to successfully perform the check:

How to view eligibility check results

Once the eligibility check is completed, you'll see a preview of the most recent check:

• The date the eligibility check was submitted on,
• The Insurance Company the check has been run for,
• The actual Plan/Coverage Dates reported by the insurance company,
• The status of the eligibility check.

To review the detailed eligibility check results, click on Details in the preview:

Along with the basic patient details, you'll now see a convenient breakdown of different kinds of benefits. Unfold any tab to see the detailed information.

Below are a few examples of the benefits to look into if provided by the payer:

1. Verify the coverage dates, covered services and other plan details under Active Coverage,

2. Verify the applicable Co-Payment and Co-Insurance amounts for various service types, as well as the period they apply to:

3. Turn to the Deductible tab details to view applicable amounts for the calendar year, amounts paid to date, and remaining balances,

4. Check for plan Limitations and Out Of Pocket amounts.

How to view the original response from the payer

At times, a payer may return some extra, non-standardized information that cannot be reflected on the user interface. For cases like that, you have the option to review the original response as received from the payer.

1. Upon looking through the benefits, click on the three dots next to any to see an excerpt form the original payer response associated with this particular benefit,

2. To review the full response as returned by the payer, click on View Original File at the top right corner. Open the downloaded .json file in any text editor (e.g.: Notepad).

Contacting the payer to verify additional details

Some payors may include contact details directly into the Eligibility results.

If you require further clarifications on eligibility and benefits, check if the Eligibility results happen to have a Contact Following Entity tab with payer-suggested contact information.

 

How to use Eligibility History

Reviewing the history of eligibility checks allows providers to verify when an eligibility check was last performed for the patient, and by whom.

Eligibility History is available for each insurance plan under the More Actions button:

Here you can find all relevant information on previously submitted Eligibility Checks:

• Date and time of submission
• On behalf of which provider the check was performed
• The plan/coverage period provided by the insurance company
• The status of the check
  • Completed - the results are available for review
  • Failed - the payer or the clearinghouse responded with a rejection message
  • Error - the system wasn't able to submit the check successfully
• Who requested the eligibility check

From the Eligibility History menu, you can review responses from the payers for the old checks that have the Completed status. check date, and the results will open in a separate tab:

The results of the any eligibility checks can be printed from Eligibility History as well:

1. Click on the three dots next to the corresponding check, and click Download PDF:

2. The print preview will open:

You can also view the reasons why certain previous checks failed. Such checks would have the Error status in case of any submission errors, or Failed status in case the check has been rejected by the clearinghouse or insurance company.

1. Click on the check date of the failed check to view the Error Details (use the Print option if needed):

2. Alternatively, click on the three-dot menu next to the failed check to Download PDF and review the Error Details in it (use the Print option if needed):

How to interpret eligibility check errors

When an eligibility check is submitted to a payer, errors or issues can occur for various reasons. Some common reasons for errors in electronic eligibility checks include:

1. Data Entry Errors: Mistakes can happen during the data entry process, leading to inaccuracies in patient information or insurance details. Even a small typo in a patient's name or insurance ID can result in an error.

2. Incomplete Information: If the practice does not provide all the necessary information required for the eligibility check, the payer's system may not be able to process the request correctly. Missing or incomplete data can lead to errors.

3. Outdated Information: Insurance information can change frequently, and if the practice is using outdated or incorrect insurance details, the eligibility check may produce errors. Keeping patient information up to date is crucial.

4. Mismatched Information: If there is a discrepancy between the information provided by the practice and the payer's records, errors can occur. This can happen if the patient's name, date of birth, or insurance details do not match what the payer has on file.

5. Authorization Requirements: Some insurance plans require prior authorization for certain services. If the practice does not obtain the necessary authorizations before submitting the eligibility check, it may receive errors indicating that the service is not covered.

6. Payer-Specific Rules: Each payer may have its own specific rules, coding requirements, and eligibility criteria. Failure to adhere to these payer-specific rules can result in errors when submitting eligibility checks.

When your eligibility check returns one of the errors listed above, the check status will be Failed and will show the error message.

 

How to view the number of submitted checks per practice

Understanding how many eligibility checks are submitted monthly is essential for effective revenue cycle management, compliance, cost control, and overall operational efficiency. This information helps making informed decisions, allocating resources wisely, and ensuring services are being provided to patients with valid insurance coverage, ultimately contributing to financial stability and quality patient care.

The Eligibility Checks report providing these insights is available in the Reports tab in the RCM.

Download the Excel file to review details on all submitted checks including general information.