On the Payer-Provided Eligibility Details page, you can:
- Verify a patient's insurance eligibility for participating insurance plans, for various dates of service.
-
Resolve eligibility demographics conflicts that occur when the information on file in your practice is different from the payer's information.
-
View benefit coverage details received from the payer, organized by their associated Service Type.
-
View the detailed history of electronic eligibility checks for a patient.
The athenaOne system retrieves eligibility information from insurance carriers that provide eligibility information electronically whenever the payer sends it to us via the ANSI standard transaction.
To display the Payer-Provided Eligibility Details page: On the Quickview page, under the Insurances heading, click View eligibility detail and history.or click Perform eligibility check.
Electronic eligibility check results reflect payer data at the time of the electronic query. The results do not take into account the date of service of the appointment.
Note: If the enrollment status for the provider is set to any status other than COMPLETE, the eligibility transaction is not sent and the following error is returned when eligibility is automatically or manually checked: "This provider is not enrolled for electronic eligibility checking."
The athenaOne system formats and displays whatever information we receive from the payer. If the payer's electronic eligibility file contains formatting or data errors, these anomalies also appear on the Payer-Provided Eligibility Details page.
Note: Most payers use the ANSI standard for eligibility transactions; athenaOne provides expanded benefit information whenever the payer sends the ANSI standard transaction.
athenahealth has a dedicated team that works to establish electronic eligibility checking for as many payers as possible. However, athenahealth can provide electronic eligibility checking only for payers that are willing and able to make this information available to us electronically.
After we establish electronic eligibility checking for a payer, it is important to understand that:
- athenahealth has no control over the availability of the payer's electronic eligibility system.
- athenahealth has no control over the accuracy of the electronic eligibility information that the payer transmits.
In other words, the availability and accuracy of our electronic eligibility checking depends on the availability and accuracy of each payer's system. athenahealth actively tracks payer status and helps payers improve the availability and accuracy of the information they do provide.
In spite of our best efforts to increase our payer coverage and the reliability of this information, a payer may deny a claim even when athenaOne receives a "Member is eligible" response from the payer.
- "Member is eligible" indicates that the patient is on file at the payer with active coverage, but it does not guarantee that a given claim will be paid.
- Benefit coverage depends on the type of service, provider network status, and patient classification on the policy.
- Eligibility information must be applied correctly to a patient encounter to effectively prevent a denial.
Refer to Eligibility Verification to view the current list of payers that have electronic eligibility checking enabled with athenahealth.
The results of the most recent eligibility check information appear on the patient's Quickview page to indicate whether a patient is insured for the date of service; copayment information or restrictions are also usually supplied in the eligibility message.
When a patient's eligibility is checked electronically, these fields on the Add /Update Policy Details page are updated: Eligible status, Last inquiry, and Last eligibility message.
From the Workflow Dashboard, you can click a linked number in the Eligibility column to access the Eligibility Worklist for that department (in the Task Bar). The worklist provides appointment date, patient name, and a link to the patient's Quickview page for each patient on the list.
The Eligibility and Phone page also provides you with information about patient eligibility (On the Main Menu, click Calendar. Under APPOINTMENTS, click Eligibility and Phone List).