Eligibility Checks
Verify patient insurance coverage and benefits
Eligibility checks verify a patient's insurance coverage and benefits in real time. Each check contacts the insurance payer and returns coverage status, benefit details, and plan information.
Viewing eligibility checks
Navigate to Eligibility from the main menu to see all eligibility checks in a paginated list.
Table columns
Check Date
Date and time the check was created
Patient
Patient name, date of birth, and chart ID
Insurance
Insurance provider name
Member ID
Policy number and group number
Status
Check status (Pending, Eligible, Ineligible, Needs Review)
Eligibility
Coverage status (Active, Inactive, Terminated, Unknown)
Filtering
Use the filter bar to narrow results by:
Status — Pending, Eligible, Ineligible, or Needs Review
Payers — filter by insurance provider
Eligibility Status — Active, Inactive, or Unknown
Check Date — date range
Sorting
Sort by check date, patient name, status, or insurance provider — in ascending or descending order.
Search
Use the search bar to find eligibility checks by ID (e.g., ELIG-123).
Creating an eligibility check
Click the Check Eligibility button to open the form.
Fill in the required fields:
Patient
Yes
Select a patient (only patients with insurance plans are shown)
Insurance Plan(s)
Yes
Select one or more of the patient's insurance plans
Ordering Physician
Yes
Select the healthcare provider
Service Date
Yes
Date of service (defaults to today)
Service Type Codes
No
Defaults to Health Benefit Plan Coverage
CPT Codes
No
Search and select procedure codes
Diagnosis Codes
No
Search and select diagnosis codes
Click Submit to run the eligibility check.
If you select multiple insurance plans, a separate eligibility check is created for each plan.
Enable the Create More toggle to keep the form open after submitting, allowing you to quickly run multiple checks in a row.
Creating from a treatment
When creating an eligibility check from a treatment detail page, the physician, service date, CPT codes, and diagnosis codes are automatically populated from the treatment.
Eligibility check statuses
Pending
Check has been submitted and is waiting for a response from the payer
Eligible
Patient is eligible — coverage is active
Ineligible
Patient is not eligible — coverage is inactive or terminated
Needs Review
The payer response contains errors that require manual review
Failed
The check could not be completed due to a system error
Coverage statuses
Active
Insurance coverage is currently active
Inactive
Insurance coverage is not active
Terminated
Insurance coverage has been terminated
Unknown
Coverage status could not be determined
Eligibility check details
Click View Details on any eligibility check to open its detail page. The detail page includes the following sections:
Overview
Eligibility check ID (e.g., ELIG-123)
Check status and coverage status
Check date and verified date
Ordering physician
CPT codes, diagnosis codes, and service type codes
Insurance information
Insurance company and insurance type (e.g., PPO, HMO, POS)
Plan coverage name
Member ID and group number
Eligibility status
Coverage status
Verification notes or error messages
AI-generated coverage summary
Recheck button to re-run the eligibility check with current data
Benefits
A detailed breakdown of the patient's benefits, including:
Deductible
Amount the patient must pay before coverage begins
Copay
Fixed amount per visit or service
Coinsurance
Percentage the patient pays after the deductible
Out-of-Pocket Maximum
Maximum the patient pays in a coverage period
Limitations
Coverage limits or restrictions
Non-Covered
Services not covered by the plan
Each benefit displays:
Network status (in-network or out-of-network)
Coverage level (individual or family)
Time period (calendar year, remaining, or lifetime)
Dollar amount or percentage
Use Expand All / Collapse All to toggle benefit details.
Right-side panel
Patient — patient demographics
Documents — upload or download related documents
Notes — add notes to the eligibility check
Activity Log — view change history
Data mismatches
If the payer response contains patient information that differs from your records (e.g., name spelling, date of birth), a warning banner appears on the detail page. Click View Details to see each mismatch with the on-file value and the payer's response.
Rechecking eligibility
From the eligibility check detail page, click the Recheck button to re-run the verification with the same parameters. This creates a new eligibility check with updated results from the payer.
Linking to treatments
Eligibility checks can be linked to treatments. When linked:
The eligibility check status is synced to the treatment's workflow steps
The check appears in the treatment's linked records section
You can link an eligibility check to a treatment when creating the check, or from the treatment detail page.
Printing
Click the Print button on the detail page to generate a print-friendly view of the eligibility check, including all coverage and benefit details.
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