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Electronic Claims

Realtime Eligibility Inquiry

This document outlines overview of ChARM EHR 'Realtime Eligibility Inquiry' feature. ChARM uses Optum EDI to get the patient insurance eligibility information. This feature will be enabled only to the practices signed up with Optum with a suitable plan to use this feature.

Eligibility Payers List

ChARM uses Optum EDI service to get the patient insurance eligibility information. List of payers supporting real time eligibility request is under 'Settings ~> Billing ~> Realtime Eligibility - Payers List'. Payers can be searched using payer name or payer id.
Eligibility Payer List

Check Insurance Eligibility

  1. For the practices enabled with this feature, 'Insurance Eligibility' link will be enabled in the patient dashboard and in appointment list view
    Insurance Eligibility Option
  2. Clicking on this link takes user to 'Insurance Eligibility View' where date of service, service type code, patient insurance and provider can be selected to complete the eligibility check
    Insurance Eligibility
  3. Insurance selection: All the patient insurances added earlier will be listed here. Payer name is shown in the drop down along with "Eligibility Supported" or "Eligibility Not Supported" text. This additional text indicates whether eligibility check is supported for this payer or not.
    Insurance List
  4. Add Insurance & Edit Insurance - Option to add new insurance and edit selected insurance is provided in this page.
  5. Patient details are shown in the right hand side, which will be sent in the eligibility request. Using these details, payer database will be searched for the patient insurance. Hence these patient details are called search options. Some payers need patient additional details such as SSN, Medicare ID, Card Number etc.
  6. Providers (Eligibility response receiver) list shows all the providers and the facilities in the practice.
    Select Provider
  7. Service Type - Service Type drop down lists all the service types supported by the payer. Practice can set the preferred service type for the eligibility verification from 'Settings ~> Billing ~> Bill Settings ~> Realtime Eligibility Settings'. This service type code set by the practice will be selected by default in this list
    Service Type
  8. Click on 'Check Eligibility' button after selecting appropriate details. ChARM sends eligibility request to Optum clearing house and renders the response in readable format. Sample response is below
    Insurance Eligibility Info
  9. Eligibility information is separated based on the service type code in the response received. Select the service type code on the right side to view the eligibility details for the specific service type
    Insurance Eligibility Details
  10. Eligibility benefit information is stored and the same can be accessed at a later point of time. To access the past eligibility details click on 'Eligibility History' link available at the top
    Sticky Note

Insurance Eligibility History of a Patient

  1. Eligibility benefit information is stored and the same can be accessed at a later point of time. To access the past eligibility details click on 'Eligibility History' link available at the top
    Insurance Eligibility History
  2. All the past eligibility benefit details will be listed in chronological order. Selecting any past eligibility request from the list will show the respective eligibility detail.
    Insurance Eligibility Enquiry

Typical Error Messages

  1. Missing mandatory details: For each payer there are some mandatory details to complete the eligibility request. When these mandatory details are missing, ChARM prompts user for these details
    Insurance Eligibility Response
  2. Missing/Incorrect Information: Optum will respond with the benefit information, if there is matching insurance details for the patient. Failing which, Optum responds with error message. Following is one such error case. In this case, patient name and date of birth (DOB) in the demographics is not matching with the payer database.
    Insurance Eligibility Response
  3. Timeout error: If ChARM does not receive response from Optum with in 60 seconds, timeout error will be shown. Refer the below screen shot. User can send the eligibility request after few minutes
    Insurance Eligibility Response

Check Eligibility from Appointment List View

'Insurance Eligibility' link is also provided in appointment list view for easy verification of the eligibility details by the front office accessing this view
Insurance Eligibility From Appt