Eligibility Detail

 

On the Patient Actions Bar, click Registration, and then click Check Eligibility. If the patient has only one policy registered in athenaOne, the Eligibility Detail page appears

 

On the Quickview page, under the Insurances heading, click view detail 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 Eligibility Summaries page and the Eligibility Detail 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).

 

 

The information provided via electronic eligibility checking can vary from payer to payer, and even from patient to patient, based on the individual policy details.

Basic Eligibility section
Eligibility	Message result of the most recent eligibility check (for example, Member is eligible).
ID/Certification Number	Member ID/certification number on the policy.
Policy/Group Number	Group/policy number on the policy.
Eligibility PCP	Primary care physician returned in the most recent eligibility check.
Eligibility Checked	Date of most recent conclusive eligibility check. Eligible, ineligible, and patient not found responses are considered conclusive.
Eligibility Notes	Verification note of the most recent eligibility check. This field appears only if no ANSI message was included in the most recent eligibility check (for example, for a failed check or for a "waiting for payer response" result).
Disclaimer	Contains the standard benefit disclaimer message. This field appears only for eligible and ineligible responses.
Patient/Subscriber Differences section
	athenaOne compares the information returned by the payer to the demographic information on file in athenaOne. Any discrepancies are listed in red in this section.   These discrepancies appear for "eligible" responses only. A row appears in this section if the following conditions are true: Payer returned a value for that row. Value is different from what we have on file (values are case insensitive). Relationship to insured on the policy is "Self." Values in athenaOne that conflict with the data returned are displayed in red with instructions to correct them on the Add/Update Policy Details page.
Payer Subscriber (or Payer Patient) Demographic Information section
	This section displays any subscriber or dependent demographic information received in the eligibility response from the payer.

Benefit Detail section
Benefit Type Category	To make identifying the correct type of service easier, we grouped service types into the following categories: Standard, Primary Care, Facility, DME, Dental, Diagnostic, Home Health/Longterm Care, Mental Health, Prescription, Specialty, Therapy, Transport, Vision, and Wellness Management. Standard, Primary Care, and Facility appear at the top of the Benefit Detail section, with all other categories following in alphabetical order. If no benefit information was supplied by the payer for a category, that heading does not appear.
Benefit Type of Service	All information received from the payer is displayed as collapsible/expandable sections, based on the benefit type of service (for example, "Health Benefit Plan Coverage"). Benefit information with no specified type of service is displayed as type "Standard."
Benefit Information Type	Displayed as an underlined heading within the collapsible Benefit Type of Service (for example, "Active Coverage"), based on the information type returned by the payer. All benefit information should have a Service Type (required by ANSI), but if Service Type is missing, the default is "Standard."
Service Level	Displayed as a column to the left of the benefit information (for example, "Family"). If the service level is unspecified, it is listed as "Standard."
Plan Network	Displayed as a bolded heading above all tables with values In Plan Network, Out of Plan Network, and Plan Network Unknown.