Viewing Eligibility Status 

You can view the status of Eligibility Verification requests. 

The Eligibility Statuses are Pending, Verified, Denied, Failed, or Not Submitted.

  1. Do one of the following:

    • Branch: Intakes > Add or Edit Patient > Insurance Coverage

    • Branch: Client > Financial Record > Payers

  2. Status appears in the Eligibility Status column.

Pending

  • Appears if a request is submitted and a response is not received. 

Verified or Denied

  • If an eligibility request successfully processes, status is either Verified or Denied, based on the Intake's or Client's eligibility with the payer.

  • If the first or Last Name, policy/id number, or date of birth you submit does not exactly match the information on the Payer's file

    • Some Payers fail the request.

    • Some Payers verify the request and highlight mismatched information with red text on the response. If information appears in red text, verify and update the information in your record as required. 

      Important

      Failure to update mismatched information in your record can result in claim rejection or denial.

Failed

  • Status is Failed if the Eligibility request is submitted but cannot be processed. For example, if required information is missing, or you submit a request and the Payer’s EDI is down.

  • In the Error column. you can read instructions to resolve the issue. 

  • The response report includes information on why the request failed verification. If instructions are to log a case for Support, enter in the case:

    • Subject/Title of Request: Elig- Response Status: Error.

    • Payer Name.

    • txn_id number located on the response report.

Not Submitted

  • Appears if the request is not sent because the Payer does not have an Eligibility Payer ID.

  • The Payer ID list is updated periodically adding new payers and updated payer information. If a payer is no longer effective, the Payer is deleted from the list. If a request is submitted and the payer is deleted from the list, the Status is Not Submitted.

  • If a response has Not Submitted Status, there is no report to view or re-verify. For Not Submitted response status, check with your organization's configuration specialist if Eligibility Verification is available and setup for the Payer.

Note

Responses from the weekly process can have Status: Failed or Not Submitted. For information on correcting the issue, read the message in the Error column. After correcting the issue, if required, re-verify eligibility in Intake Insurance Coverage or Client Payers.

  • You must include at least the following information for Eligibility Verification: branch NPI, Eligibility Payer ID, patient last name, first name, date of birth, Social Security Number (SSN), and member ID.

  •  Failed status is frequently because resident demographics and/or insurance information in Home Care does not match the information in the payer's file. You must compare all demographic and insurance information in Home Care and the payer's file, and update information in Home Care to match the payer's file. After all information matches, in A/R Insurance, you must re-verify. If status is still Failed, log a Support case.

  • Medicare limits the number of failed verifications on the same Medicare number and NPI to 5 attempts within 24 hours. If you exceed the limit, an error message appears. To avoid exceeding the limit, before you re-verify Eligibility, verify the cardholder information including the Name, DOB and Medicare number you entered.