Eligibility: checking insurance
Verify patient insurance eligibility in real-time.
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- eligibilityinsuranceverification
Eligibility checks verify a patient's insurance coverage before the visit. This article covers running checks, interpreting results, and handling failures.
Running a check
From the patient chart, go to Billing → Eligibility → New check. Select the payer and enter the member ID, date of birth, and date of service (usually today or the appointment date). Click Check eligibility. The request goes to the clearinghouse and returns in 5-30 seconds.
Understanding results
The response shows: Coverage status (active/inactive), Plan name, Copay amount, Deductible (total and remaining), Out-of-pocket max, Effective dates. Green = active coverage. Yellow = coverage found but with warnings (e.g., out of network). Red = no coverage found or inactive.
Copay and deductible
The copay field shows the patient's responsibility for a standard office visit. Deductible shows how much they've met vs total. If deductible is not met, the patient may owe the full contracted rate. These are estimates — the payer's final determination on the claim is binding.
When checks fail
Common failure reasons: Member ID not found (check for typos), DOB mismatch, Coverage terminated, Payer not supported. If you get "Payer not supported", you can still submit claims but eligibility must be verified by phone. For other errors, verify the patient's card and try again. You can also call the payer directly.
Batch checks
For tomorrow's appointments, go to Billing → Eligibility → Batch check. The system runs eligibility for all patients with appointments in the next 1-7 days (configurable). Results appear as a list; filter by status to see who needs follow-up. Batch checks run overnight automatically if enabled.
History and audit
Every eligibility check is saved to the patient's record with timestamp, user, and full response. This is useful if a payer later denies a claim for eligibility reasons — you have proof of what their system returned at the time. History is under Billing → Eligibility → History.
Frequently asked questions
How often should I check eligibility?
What if eligibility shows active but the claim is denied?
Keep reading
Submit your first claim, end-to-end
From visit close to ERA posting — every step in order with the gotchas called out.
Handling denials
How the denial queue works and how to appeal common denial reasons quickly.
ERAs and patient payments
Auto-posting from the clearinghouse, manual posting, and reconciliation.