Checking eligibility within the Medical Billing software allows users to confirm a patient’s active insurance coverage and review benefit details before submitting a claim. This process helps ensure services are reimbursed appropriately and reduces the likelihood of claim rejections caused by inactive coverage or unmet plan requirements. .

By verifying eligibility in advance, providers and billing staff can review important information such as coverage status, copay amounts, deductible balances, and plan limitations. This provides greater visibility into what the insurance plan will and will not cover for a specific date of service.

Run eligibility

Eligibility can be run from multiple areas within the system, including the Eligibility tab and the Patient Dashboard, allowing users to quickly verify a patient’s active coverage and benefits information.

Eligibility tab

From the Application Dashboard, click Eligibility in the top navigation bar.

On the Eligibility screen, click Request Eligibility to initiate a new eligibility check for a specific patient. 

Enter the Patient Name, then select the appropriate Case, Payer, Eligible Payer, and Provider from the corresponding dropdown menus. Next, enter the Service Date to continue setting up the eligibility request.  

To run eligibility by Service Type, select the Service Type option, then choose the appropriate service type from the Service Type dropdown menu. This allows the system to verify coverage based on the category of service being provided, helping ensure the selected services are covered under the patient’s plan.  

To run eligibility by CPT code, select the CPT Code option, then use the CPT Code search field to locate and select the appropriate CPT code. 

After selecting either the service type or CPT code, click Check Eligibility to submit the request and retrieve eligibility results.  

On the Eligibility screen, the grid displays key details for each request, including the Date Requested, Patient Name, Payer, and Requested By, along with a View button. Click View to open and review the patient’s active coverage and benefits information. 

Patient dashboard

Navigate to the Patient Dashboard and click the Eligibility icon located in the demographics section to access the patient’s eligibility screen.

Select the patient’s case from the Cases dropdown menu, then select the appropriate payer from the Case Payers dropdown menu. 

Select the provider associated with the appointment from the Rendering Provider dropdown menu, then enter the appropriate date of service in the Service Date field. 

Eligibility can be verified by either Service Type or CPT Codes. 

To check eligibility by service type, select the By Service Type checkbox, then choose the appropriate service type from the Service Type dropdown menu. This option allows the system to verify coverage based on the category of service being provided. 

To check eligibility by CPT code, select the By CPT Code checkbox, then use the search icon to locate and select the appropriate CPT code. 

On the Search CPT Code pop-up screen, enter the CPT code in the Code field, or type a brief description in the Description field, then click Search to view the results. 

The matching code and description will appear in the search results. Select the appropriate code from the list, then click OK to confirm your selection. 

After selecting either the service type or CPT code, click Check Eligibility to submit the request and retrieve eligibility results. 

Eligibility logs

Eligibility logs provide a comprehensive record of all eligibility checks performed for a patient, including both automatic and manual transactions. These logs allow you to easily track when eligibility was verified and review historical activity related to a patient’s coverage. By accessing the eligibility logs, you can quickly identify prior eligibility attempts and ensure that all dates of service have been properly processed. 

Click the icon in the View column to open and review the eligibility log. You also have the option to download the 270/271 transaction logs for reference or recordkeeping.  

• 270 (Eligibility Inquiry): This is the request sent to a payer to determine a patient’s insurance eligibility and benefits. It includes information such as patient demographics, insurance policy details, provider information, and the date of service.
• 271 (Eligibility Response): This is the response returned by the payer. It includes eligibility results such as coverage status, coverage dates, copay, deductible, and other benefit information, depending on what the payer supports.

View eligibility

The View Eligibility screen provides comprehensive health benefit coverage details for the selected patient. The left-hand panel displays a breakdown of the available information, organized by section for easy navigation.

To quickly view specific details, click on any section heading in the left panel. This will automatically take you to the corresponding section of the eligibility results. 

You can also print the eligibility information by selecting the Print option located in the upper-right corner of the screen. 

Automatic batch eligibility

When this feature is enabled, the system will automatically run eligibility checks overnight for all patients who have encounters listed in the Unbilled tab of the Encounters screen. This automated process helps ensure that insurance coverage is verified prior to claim submission, reducing the risk of billing delays and eligibility-related claim rejections.

The overnight eligibility process reviews each patient’s insurance information and retrieves current coverage and benefit details from the payer. This allows billing staff to identify issues such as inactive coverage, invalid policy information, unmet deductibles, or plan limitations before claims are generated and submitted.

Click Utilities on the top right side. 

Click on Preferences, then click on Company Preferences.

Scroll down to the Eligibility Settings and Toggle on Batch Eligibility.

Click Save. 

You’ll need to log out and log back in to ensure the preferences are applied. 

You can access unbilled encounters by clicking on Encounters in the top navigation bar or selecting Unbilled Encounters from the Alerts section. 

The Eligibility column displays the status of the eligibility check.

• Un-initiated - This means, the record wasn't a part of any previous eligibility batch check. You can hover over the icon to see the tooltip. 
• Success - This means, the eligibility run is complete and the report is available for viewing. 
• System Error - This means, eligibility could not run because of a system error. You can hover over the icon to see the tooltip. 
• In Progress - This means, the eligibility check is in progress. 
• Error - On hover, you'll see a tooltip with comma-separated validations listed.

Click View Batch Report to view the report links for every record with a successful eligibility check. The pop-up can be printed in PDF format.  

You can manually run an eligibility check from the unbilled encounters tab by clicking the Run Eligibility button. 

A confirmation pop-up will appear with the following message:

“Are you sure you want to run eligibility? Eligibility will run for all encounters in the Unbilled - Review tab with a Service Date within the last 6 months.”

Click Confirm to proceed with the eligibility check process. Once confirmed, the system will begin running eligibility verification for all qualifying encounters that meet the date-of-service criteria.

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