Eligibility

Eligibility allows you to efficiently confirm information received from a verification of benefits call. Eligibility is an electronic inquiry sent to the payer’s system through our clearinghouse. The payer sends back a response with basic benefit information. In most cases, eligibility does not replace the need for benefit verification. Eligibility is not supported by all payers and is not available for paper payers.

Eligibility Requirements

All required patient, payer, subscriber, and policyholder information must be entered before an eligibility inquiry can be sent. In a patient’s Policy Holder tab, eligibility will be run automatically when Verify Eligibility on Save is set to Yes. 

Note: If the Verify Eligibility on Save option does not appear, the payer does not support electronic eligibility.

If any of the patient information entered differs from what the payer has in their system, a notice will populate, prompting the user to correct or ignore.

For a complete eligibility overview, click on the Eligibility tab. Inquiries can also be run directly from here.

Set the Service Date that eligibility should be checked for and choose a Service Type from the drop-down list. By default, the system will run eligibility by the service type Substance Abuse first. If eligibility cannot be determined, it will re-run eligibility by Health Benefit Plan Coverage. 

The different types are:

• Health Plan Benefit Coverage
• Mental Health
• Mental Health – Facility – Inpatient
• Mental Health – Facility – Outpatient
• Mental Health – Provider – Inpatient
• Mental Health – Provider – Outpatient
• Physical Therapy
• Substance Abuse
• Substance Abuse – Facility – Inpatient
• Substance Abuse – Facility - Outpatient

To print an Eligibility response, select Print Eligibility. This can be used as proof of active coverage or a point of reference when following up on claims.

Historical Eligibility

Previous Eligibility responses are accessible in the Records Center. Navigate to Records Center > VOB > Eligibility History.

Select your Organization and Start and End Date Range. To further narrow the results, choose a Practice and Payer. Historical data is available for inquiries run on or after 9/10/18. To view a PDF of the Eligibility response click View Eligibility.

To use the resulting table data for reporting, click Download to Excel. 

Common Eligibility Responses

A successful eligibility response is not required before claims can be sent. Eligibility should be used to supplement a verification of benefits. Do not use eligibility in place of a VOB. When in doubt, call the payer to obtain the correct information.

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.

Active

The patient’s plan is active. The benefit information is generated by the payer. 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.

Inactive 

 The patient’s plan is no longer active, or 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 Avea to the patient’s insurance card or verification of benefits. For questions about the content of the response, or assistance contact the payer.

Mixed Coverage

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.

Subscriber Not Found

Based on the information submitted, the payer was not able to locate the policy.

Unspecified 

The payer found the member or dependent in their database, but the response received from the payer did not contain a definitive Active or Inactive status.  See the details on the response for more information.  This is not a failed status and will require reviewing the response completely. The inquiry will often list an entity to contact for additional benefit information.

Failed at Payer

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 Avea to the patient’s insurance card or verification of benefits. For questions about the content of the response, or assistance contact the payer.

Example:

• Invalid / Missing Subscriber / Insured Name
• Invalid/Missing Provider Identification
• Invalid/Missing Patient Name
• Invalid Participant Identification
• Provider Ineligible for Inquiries
• No Response Received in the Expected Time Frame - Transaction Terminated
• Unable to Respond at Current Time
• Patient Birth Date Does Not Match That for the Patient on the Database

 

Failed at Zirmed/Waystar

The eligibility inquiry submitted could not be fully processed. This often means necessary information is missing.

Examples:

• Required application data missing: There is not enough information entered to complete the inquiry. Go back to the policy holder tab and ensure that all necessary fields are filled out.
• Authorization/Access Restrictions. Entity is not authorized to submit eligibility inquiries to this payer: Verify if enrollment is required for eligibility inquiries in Practice Admin > Payers.
• Invalid/Missing Provider Name: Verify that provider information is entered correctly. The first time an eligibility inquiry is run through the system for a provider, support staff must go through a step called, Name-Matching. This can only be done after the first inquiry is submitted and fails. If the provider is new to Avea, or new to running eligibility, and this error comes up, please contact [e-mail]. Let support staff know that the inquiry is failing for this reason and provide a link to the patient.