Eligibility verification is the process of checking a patient’s active coverage with the insurance company to verify information such as coverage, copays, deductibles, and coinsurance.
Patient’s insurance information can change at any time, potentially causing claim rejection or denial, so it's important to verify the 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 how to:
- Activate eligibility check in the EHR
- Conduct eligibility check
- View eligibility check results
- Common eligibility check errors
How to Activate Eligibility Check in the EHR
To verify a patient's insurance eligibility, you must have the integration with Remedly Revenue Cycle Management solution (RCM) in place. Otherwise, you'll get the following message pop up at the attempt of Eligibility Check.
RCM is provided at an additional cost - please reach out to support@remedly.com for pricing and more information about Remedly's medical billing solutions.
To learn more about Remedly's RCM, visit our web site:
Enrollment is typically required with each payer for submitting eligibility checks. This process may take some time for setup and some payers do not provide eligibility check digitally.
How to Conduct Eligibility Check
When the integration between your EHR and RCM is enabled and enrollments with insurance companies are completed, you can start to verify eligibility in the EHR.
IMPORTANT: Please ensure that the Main Doctor of your practice with the Admin rights has saved their NPI in their Account Settings. The NPI must be the same NPI used for enrollment with your clearinghouse (TriZetto or Claim.MD) for eligibility checks.
All users, regardless of their roles in the EHR, possess the capability to check eligibility under the main provider's account NPI if the NPI is entered and saved in the main provider's Generic Provider Account Main Menu>Account Settings > Name and Login information:
Note: Eligibility Checks are enabled only with a current date.
VERIFY ELIGIBILITY IN RCM: to verify a patient's eligibility via the RCM, there needs to have been at least one chart/procedure note already committed for the patient since this establishes the patient account in the RCM.
To learn more about eligibility checks in the RCM, please see the following article:
Eligibility Check in the EHR can be initiated from the following places:
Check Eligibility from Individual Patient History
In the patient chart, you can initiate an Eligibility Check from two places:
- insurance policy input form
- saved insurance policy
Check Eligibility from Invoice with Charge to Insurance
If you wish to verify eligibility from within an invoice, follow these steps:
1. Edit the procedure/inventory line item then switch from Charge to Patient option to Charge to Insurance option, since Charge to Patient is the default.
2. The Insurance section will now appear enabling you can click Check Eligibility for this line item.
The results will appear on your screen:
You can read about the patient's plan benefits by scrolling the list. When finished, click OK at the bottom of the list.
To close the patient's insurance benefits, click the X in the top right corner.
Check Eligibility from Appointment for Primary Insurance
When an appointment is scheduled, you can verify a patient's primary insurance eligibility from the Calendar as follows:
1. Locate the appointment on the Calendar and click on the bottom-right corner of the appointment. A small window will pop up enabling the ability to verify eligibility and document Copay if needed.
2. Click the Verify button.
The eligibility check results for the Primary insurance plan will display.
Where to View Most Recent Eligibility Check Results
To view the most recent eligibility check results, follow these steps:
1. From the patient's chart, click on the Pencil icon.
2. Scroll down to find the saved insurance details.
3. Click on the date button under Last eligibility check to view the eligibility check results derived on that date.
The list will pop up on your screen with the patient's insurance coverage details:
Common Eligibility Check Errors
The following error may pop up if an insurance company does not support real-time eligibility check. You may need to contact the insurance company directly to verify a patient's eligibility.
The following error pops up when a Provider's NPI is not saved in their Account Settings.
The following error appears when a provider's NPI is not valid.