Check Eligibility

You can submit an eligibility check to verify patient coverage and benefits to determine patient financial responsibility for a visit. The eligibility check can be submitted at the patient level or the visit level.

Check Eligibility at the Patient Level

To check eligibility for a patient:

  1. Search for and select a patient.
  2. From the Patient Profile, select Financial Responsibility.
  3. Under Insurance, select the checkbox for the appropriate insurance and select Check Eligibility. The system processes the eligibility request. The progress and status of the submission is displayed on the applicable insurance row.

    Note:

    You can also select Check Eligibility With Options to select a beginning and end date, as well as a specific service type.

Check Eligibility at the Visit Level

To check eligibility for a patient visit:

  1. Search for and select a patient.
  2. Locate the appropriate visit on the Visit List and select Actions (...) and select Edit Visit.
  3. Select Manage Financial Responsibility.
  4. Under Insurance, select the checkbox for the appropriate insurance and select Check Eligibility. The system processes the eligibility request. The progress and status of the submission is displayed on the applicable insurance row.

    Note:

    You can also select Check Eligibility With Options to select a beginning and end date, as well as a specific service type.

View Response Details

Select Eligibility Details for more information about the eligibility response. Recommended benefits including coverage status and other relevant information are summarized. You can also select All Benefits to view all available benefits for the health plan. Under Support Information, you can view details about the inquiry itself, or view the entire response by selecting Full Response.

Apply Benefits to a Visit

AI-suggested benefits are available that can be applied to the visit. These benefits are displayed at the top of the list under Benefits.

To apply benefits to a visit:

  1. Select Eligibility Details.
  2. Under Benefits, select the plus sign (+) next to an AI-suggested benefit. Select the delete icon to remove an AI-suggested benefit.
    1. To manually apply another benefit to the visit, select Apply Benefits.
    2. Select the appropriate service and network, and select Apply Benefit.
  3. Select Save. The benefits are applied to the visit.

Manage Discrepancies

Any discrepancies identified are displayed under Discrepancies in the response summary, and a Needs Attention task is displayed.

To manage discrepancies:

  1. Select Eligibility Details.
  2. Evaluate each discrepancy and select whether to accept or reject the the discrepancy. Oracle Health recommends that you accept the discrepancy correction as suggested by the system The following types of discrepancies may be identified:
    1. Health plan (also displayed as a Needs Attention task)
    2. Demographics
    3. Secondary coverage (also displayed as a Needs Attention task)
    4. Applied benefits (also displayed as a Needs Attention task)

      Note:

      The co-pay amount is reflected in the Patient Responsibility box if the system can determine the amount from the eligibility check.
  3. Select Accept to update the system based on the information in the response. Select Reject to retain the information currently in the system or select Reset to revert the selection.
  4. Select Save to save any changes made to address discrepancies.