User Guide — Prescription Eligibility

Front desk staff should check the patient's prescription eligibility if it has not yet been checked. You can check a patient's prescription eligibility once per 24-hour period, unless an error is received.

Note: The patient's prescription eligibility information also appears on the Check-in page.

1. On the Quickview, locate the Prescription field and click check now.
   The Prescription Eligibility Detail page appears. If the eligibility check is successful, the patient's prescription eligibility details appear.
2. Click the expand all link to see the prescription coverage details, or click collapse all to hide them.
3. Display the Quickview again.
• If the eligibility check was successful, the check now link is replaced with a details link. You can click the details link to see the results of the most recent eligibility check.
• If you received an error, a check again link appears next to the error message.

Between 4:00 a.m. and 9:00 p.m., athenaOne automatically performs hourly prescription eligibility checks for appointments coming up in the next 12 hours. athenaOne also performs prescription eligibility checks automatically whenever a new order group is selected for a patient.

When you check a patient's prescription eligibility, the following process takes place.

1. athenahealth sends a standard ANSI X12N 270 transaction to Surescripts. The 270 transaction is the same transaction used to check medical insurance eligibility.
2. Surescripts uses the patient's last name, first name, middle name, ZIP code, date of birth, and gender to locate and uniquely identify matching patients in its master patient index. If more than one patient matches the criteria, Surescripts returns an error message.
3. After the patient is successfully matched, Surescripts forwards the 270 transaction to the appropriate pharmacy benefit managers (PBMs).
4. The PBM verifies the patient, responds with a standard ANSI X12N 271 transaction specifying whether the patient is eligible or not, and sends the 271 message back to Surescripts.
5. Surescripts validates the format of the incoming 271, consolidates all 271 response transactions, and sends the information back to athenahealth.