Verify Eligibility

Verifying a patient's benefits is the first step in the revenue cycle, typically involving two tasks: checking eligibility and confirming benefits by phone with the payer.

Although calling the payer may be optional, it is always recommended to confirm eligibility using any available method. Eligibility should support, not replace, benefit verification. When unsure, contact the payer to ensure accuracy.

Note: Not all payers support eligibility checks; benefits must be verified directly with the payer by phone. To confirm if a payer has an electronic eligibility system, cross-reference this list from our clearinghouse, Waystar.

User Permissions

Admin-level user profiles can perform eligibility checks without additional permissions. Managing Organization Users and Organization Users will require additional permissions before they can complete an eligibility check. For more information on user profiles and permissions, click here.

Verify Eligibility From The RCM

Most payers require the patient's name, date of birth, gender, and policy number to be present in the Policy Holder subtab before a check can be completed. There are three methods for checking a patient's eligibility in the Kipu RCM. Let's review them together!

1. Navigate to the patient profile and click the Intake quick link.
2. Next, select Insurance and click on the payer's name.
3. In the insurance set, click Eligibility.
4. Update the Service Date and Service Type when applicable.
5. Finally, click Check Eligibility to complete the process.
For information on performing an eligibility check when creating a new patient profile, click here.
1. Navigate to the patient profile and click the Intake quick link.
2. Next, select Insurance and click on the payer's name.
3. Select the Policy Holder subtab and click Edit.
4. Make the desired changes and toggle on Verify Eligibility on Save.
5. Finally, click Save to complete the process.

Verify Eligibility From The EMR

For organizations with EMR integration, follow the steps below to complete an eligibility check in the EMR.

Let's review the workflow together!
1. In the EMR, open the patient's chart.
2. Next, click Edit Patient.
3. Scroll to the Insurance Information section and click Eligibility.
4. Update the Service Day and Service Type when available; then click Check Eligibility to complete the process.

Eligibility Responses

A successful eligibility response is not required before claims can be sent. Eligibility responses will fall into one of the following categories. Error, Active, Inactive, Mixed Coverage, Subscriber Not Found, Unspecified, Failed at Payer, Failed at Zirmed/Waystar.

Error – There are two main eligibility errors.

Object reference not set to an instance of an object – Eligibility inquiries are transmitted using the Payer ID and cannot be generated for paper payers.
The remote server returned an error: (400) Bad Request – Eligibility is not supported by the payer. Verify if the payer supports eligibility in Practice Admin > Payers. Look under the eligibility column for the selected payer. ‘No’ indicates the payer does not support eligibility.

The patient’s plan is active. The payer generates the benefit information. For questions or details about the content of an active response, contact the payer. Active responses will often, but do not always, include deductible amounts, out-of-pocket maximums, and coinsurance percentages.
The patient’s plan is no longer active, or the information submitted is different from what the payer has on file. Attempt to troubleshoot the issue based on the information returned through the eligibility request. Compare the information entered in RCM to the patient’s insurance card or verification of benefits. For questions about the content of the response or assistance, contact the payer.
One or more components of the patient’s plan is inactive (dental, vision, health benefit coverage, etc.). Review the full response for details. For questions about the content of the response, contact the payer.
Based on the information submitted, the payer was not able to locate the policy.
The information provided does not match what is in the payer’s system. Attempt to troubleshoot the issue based on the information returned through the eligibility request. Compare the information entered in the RCM to the patient’s insurance card or verification of benefits. For questions about the response's content or for assistance, contact the payer.
The eligibility inquiry submitted could not be fully processed. This often means that necessary information is missing. It is important to note that the first eligibility check for a new payer will fail until name-matching is completed.

Name-matching is required by the payer to ensure that the billing provider obtaining the information is credentialed and eligible to access their eligibility system. This process can only be completed by our support team during normal business hours. For more information on contacting our support team, click here.
The payer found the member or dependent in its database, but the response did not include a definitive Active or Inactive status. See the details in the response for more information. This is not a failed status and will require a complete review of the response. The inquiry will often list an entity to contact for additional benefit information.