Eligibility Verification

Overview

Eligibility verification ensures that patients are covered by their insurance and authorized to receive services before care begins. This process helps prevent claim denials and ensures proper reimbursement.

When to Verify Eligibility

Automatic Triggers

• New Referrals: All new referrals automatically have needs_eligibility_check set to true
• Status Change: When referral status changes to active
• Insurance Update: When patient insurance information is updated

Manual Verification

• Before First Visit: Always verify eligibility before scheduling the first visit
• Insurance Changes: Re-verify when patient's insurance changes
• Periodic Review: Re-verify eligibility periodically (e.g., monthly or quarterly)
• Before Authorization: Verify eligibility before requesting service authorization

Eligibility Verification Process

Step 1: Access Eligibility Interface

1. From Referral Detail Page

   • Navigate to /admin/intake/[referralId]
   • Click on the "Eligibility" tab

2. From Patient Intake Page

   • Navigate to /p/[referralId]/intake
   • Eligibility section is displayed at the top

Step 2: Review Patient Information

Before verifying, ensure you have:

• Patient Name: Full legal name as it appears on insurance card
• Date of Birth: Accurate DOB matching insurance records
• Member ID: Insurance member ID number
• Plan Description: Insurance plan name and type
• Service Codes: CPT codes for services to be provided

Step 3: Initiate Eligibility Check

1. Click "Verify Eligibility"

   • System will display current eligibility status
   • If not verified, proceed to verification

2. Enter Required Information

   • Plan description (insurance provider)
   • Member ID
   • Service codes (comma-separated list)

3. Submit Verification Request

   • Click "Verify Eligibility" button
   • System processes the request
   • Status updates in real-time

Step 4: Review Results

1. Eligibility Status

   • Verified: Patient is eligible and authorized
   • Not Verified: Patient eligibility could not be confirmed
   • Pending: Verification is in progress

2. Review Details

   • Check coverage dates
   • Verify service codes are covered
   • Review any restrictions or limitations

3. Update Status

   • Mark as "Eligible" if verification successful
   • Mark as "Not Eligible" if verification failed
   • Add notes explaining the status

Service Authorization

Requesting Authorization

1. Select Service Codes

   • Choose the CPT codes for services needed
   • Multiple codes can be selected
   • Codes should match the services to be provided

2. Initiate Authorization

   • Click "Authorize Patient" button
   • Enter plan description and member ID
   • Select service codes

3. Monitor Authorization

   • System sends authorization request
   • Status updates as authorization is processed
   • Notification when authorization is complete

Authorization Status

• Authorized: Services are approved and can proceed
• Pending: Authorization request is being processed
• Denied: Authorization was denied (review reason)
• Partial: Some services authorized, others denied

Eligibility Status Management

Updating Eligibility Status

1. Manual Status Update

   • From referral detail page, use eligibility status dropdown
   • Select new status: eligible, not_eligible, pending, expired
   • Status updates immediately

2. Bulk Status Updates

   • Select multiple referrals
   • Use bulk action to update eligibility status
   • All selected referrals are updated

Status Types

• eligible: Patient is eligible and verified
• not_eligible: Patient is not eligible or verification failed
• pending: Eligibility check is in progress
• expired: Previous eligibility has expired
• needs_check: Eligibility needs to be verified

Best Practices

Verification Timing

• Early Verification: Verify eligibility as soon as referral is received
• Before Services: Always verify before first visit
• Regular Re-verification: Re-verify periodically, especially for long-term care
• After Changes: Re-verify when insurance information changes

Information Accuracy

• Exact Match: Ensure patient information exactly matches insurance records
• Member ID: Use the exact member ID from insurance card
• Service Codes: Use correct CPT codes for services
• Plan Details: Include full plan name and description

Documentation

• Screenshot Evidence: System automatically captures eligibility screenshots
• Status Notes: Add notes explaining eligibility status
• Authorization Details: Document authorization numbers and dates
• Expiration Dates: Note when eligibility expires

Workflow Efficiency

• Batch Verification: Verify multiple patients at once when possible
• Status Tracking: Keep eligibility status current
• Alert System: Set up alerts for expiring eligibility
• Regular Review: Review eligibility status during team meetings

Troubleshooting

Common Issues

Verification Fails

• Verify patient information is accurate
• Check that member ID is correct
• Ensure service codes are valid
• Try re-verification after a few minutes

Authorization Denied

• Review denial reason
• Verify service codes are covered by plan
• Check if prior authorization is required
• Contact insurance provider if needed

Status Not Updating

• Refresh the page
• Check for error messages
• Verify you have permission to update status
• Check network connection

Screenshots Not Capturing

• Check browser permissions for screenshots
• Verify screenshot storage is configured
• Check file size limits

Integration with Intake Process

Automatic Workflow

1. Referral Created → needs_eligibility_check = true
2. Eligibility Verified → Status updated to eligible
3. Authorization Requested → Service codes authorized
4. Intake Complete → Patient ready for care

Status Dependencies

• Before Intake: Eligibility should be verified before completing intake
• Before Scheduling: Authorization should be obtained before scheduling visits
• Before Billing: Eligibility must be current for billing submission

Related Documentation

• Referral Management
• Patient Intake
• Billing Dashboard