Eligibility checks

An eligibility check asks the payer, through the clearinghouse, whether a coverage is active and what the patient owes under it. NeatPractice keeps every answer, so you can see what the payer said and when.

The payer must be set up for electronic eligibility in Setup: turn on eligibility checks and enter its Payer ID (see Payers). Self-pay coverage has no payer to ask.

Check eligibility#

1. Open the patient's chart and click the Coverage tab.
2. Open the coverage row's menu and click Eligibility.
3. Click Check Eligibility.

The check is for today's date of service. NeatPractice asks about the services of the patient's open episodes of care (speech therapy or occupational therapy benefits, for example), or about the plan in general when the patient has none (see Episodes of care).

You need a role that can manage patient coverage to run a check or update the coverage. Anyone who can open the chart can see the results.

Every check, on demand or in the nightly run, counts toward your plan's monthly eligibility checks allowance. If your plan stops at the allowance and it is used up, the check says so and nothing is sent. See plan usage and packs.

Record a manual verification#

When the payer does not answer electronically, or your clinic does not have the add-on, call the payer or look the patient up on its portal, then write down what it said:

1. Open the coverage row's menu and click Eligibility.
2. Click Record Verification.
3. Choose how you Verified by (phone call, payer portal, fax or other) and the Plan status the payer gave.
4. Enter the Payer contact you spoke with and the Reference number for the call or portal lookup.
5. Fill in what the payer told you: plan name and dates, the visit limit and visits remaining and, under Cost sharing, the copay, coinsurance and what is left of the deductible and out-of-pocket maximum.
6. Click Save Verification.

A manual verification counts like an electronic check: it shows in the Eligibility column and the history (the Source says Manual verification), it marks the patient's next appointments as verified for 30 days, and you can copy its values onto the coverage with Update Coverage. It does not count toward your plan's eligibility checks allowance.

Read the result#

The Eligibility column on the Coverage tab shows the latest result for each coverage and when it ran:

• Active: the payer confirmed the plan covers the patient.
• Inactive: the payer found the plan but it does not cover the date of service, for example because it ended.
• Error: the payer could not answer, most often because it did not recognize the member id or the subscriber's details. Compare them with the insurance card and the payer's records, correct the coverage, and check again.

The Eligibility window shows the selected check: the plan name and dates, any visit limit with the visits left, the service types asked about, the payer's messages and, for an error, the payer's error code. Below it, a table puts each value the payer reported next to the value on the coverage. Click Show Payer Response to read the payer's full response.

The History table lists every check on the coverage, newest first. Click a check's date to see that result.

Update the coverage from a check#

NeatPractice never changes a coverage on its own. To use what the payer reported:

1. In the Eligibility window of an active check, click Update Coverage.
2. Choose the values to copy. Values that differ from the coverage are selected for you.
3. Click Update Coverage.

The payer reports how much of the deductible and out-of-pocket maximum is left; NeatPractice records how much is met, as of the day of the check. For example, a payer that reports $1,000.00 left on a $1,500.00 deductible updates the coverage to $500.00 of $1,500.00 met. The coverage then shows that its cost sharing came from an eligibility check, until someone edits those amounts by hand.