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Electronic Claims

Automatic Eligibility Inquiry

Practices can now automate Insurance Eligibility Inquiries before the scheduled Patient's Appointments. This automation streamlines the process by updating key Eligibility details, including Eligibility Status, Policy Validity Dates, Copay, Co-insurance, and Deductible directly to the Patient's Insurance. The Insurance Eligibility status is then displayed in the Calendar list view.

We also have the option to do the Eligibility Inquiry automatically when Patient Insurance gets added to CharmHealth. Practices can configure these settings to suit their needs from 'Settings > Billing-eClaims > Real Time Eligibility Settings'.

This enhancement ensures that the Providers have crucial Insurance-related details readily available before the Patient's Appointment. The feature is accessible to all customers having an account with Optum or Change Healthcare created as part of the e-Claims add-on.

We will explain in detail how the automation can be configured for these flows.

Automatic Eligibility Inquiry Before Patient Appointments

  • This option helps the Practice to enable Eligibility Inquiry automation for scheduled Patient Appointments.
    Real Time Eligibility Settings
  • The below three additional options will add flexibility in automating Eligibility Inquiries for scheduled Appointments.
    Real Time Eligibility Settings
  • The Practice can set the days for eligibility inquiries before a Patient's Appointment.
  • The second option offers to perform Eligibility Checks automatically for Appointments scheduled within the days specified in the above setting.
  • The last option in the above screenshot allows Practices to bypass Eligibility Inquiries if they were already conducted within the specified timeframe, thus preventing duplicate inquiries.

Option to do the Eligibility Inquiry when the Patient Insurance is Added

  • This option helps Practice to enable Eligibility Inquiry when a Patient's Primary Insurance is added.
    Real Time Eligibility Settings

Eligibility Inquiry - Fields updated from Eligibility Response to Insurance

The following fields would be updated in the Patient's Primary Insurance after Eligibility Inquiry Check.

  • Insurance Eligibility Status - This field will be updated by default. The available Eligibility Status are Eligible (Insurance is eligible), Not Eligible (Insurance is not eligible), and Unknown (Eligibility could be not performed or status could not be found).
  • Policy Valid From/Until Date
  • Additional Eligibility Details (Deductible) - This field in the Insurance will contain Deductible related information.
  • Copay - CharmHealth will try to determine the right copay from the Eligibility Inquiry response and update the Insurance. If it cannot be determined from the Eligibility Inquiry response, then this field will not be updated.
  • Co-insurance
  • If the default Service Type is '30- Health Benefit Plan Coverage', then '98- Professional (Physician) Visit' would be considered for automatic calculation of Copay/Co-insurance/Deductible.
    Real Time Eligibility Settings
    View Insurance - Additional Details

Practices can also choose to update the mentioned fields in the Primary Insurance for manual Eligibility Inquiries.

Insurance Eligibility Details shown in the Calendar Section

Insurance Eligibility Details can be viewed in the Calendar section by clicking the icon before the Payer name, as shown in the screenshot below. To make the information easily recognizable, different icons are used for Eligibility Status.
Insurance Eligibility Details - Not Eligible

The icons for Eligibility Status are represented below.

Insurance is Eligible Insurance is Eligible
Insurance is Not Eligible Insurance is Not Eligible

Eligibility Inquiry Report

  1. Go to 'Billing > Reports > Other Reports > Eligibility Inquiry Report'
  2. This report lists all the Eligibility Inquiry checks done for the Patients in the Practice. It includes only successful Eligibility Checks for the Practice.
  3. You can choose to show the details, either by Eligibility Inquiry Date or Date of Service.
    Eligibility Inquiry Report

Enhancements to the 'Insurance' report in Analytics

The Patient Insurance Report under the 'Analytics > Custom Reports' section provides more information on the Eligibility details of Patients updated during the Automatic Eligibility Check.

This report allows Practices to view the Eligibility details of all Patients at once instead checking them individually.

You can also generate this report based on the Insurance Status and Eligibility Status.
Patient Insurance Report