User Guide — How to Minimize Your Eligibility Worklist

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You can improve your "first-pass" pay rate by minimizing eligibility errors. A single data issue or error can cause many eligibility errors and will continue to produce claims with eligibility errors until it is resolved. Addressing the issue now will prevent the same eligibility error from being generated for future visits or patients.

Unverified messages

This patient could not be found on the payer's files. Either the patient is ineligible or demographic information included in the inquiry (e.g., member ID) does not match the payer's files.

Cause: Patient not matched in payer's system; often due to mistyped member IDs, may be due to a name, DOB, SSN mismatch if member ID did match.
Solution: Check the Insurance Policy Details page to make sure that all information is entered properly, and check that the information on the Quickview is consistent with information entered on the Insurance Policy Details page. If so, call the payer to verify demographic info on file: member ID/certification number, name spellings, DOB, SSN, and relationship to insured are the most common errors. Some payers respond this way when the patient is "ineligible."

Could not determine eligibility. Please call the insurance company to verify eligibility. (Error detected in outgoing transaction.)

Cause: Some data element is causing the transaction to fail; often, this error is due to an asterisk (*) or other special characters that was included in the patient's name or member ID.
Solution: Call the payer to ascertain eligibility status; log the issue with the CSC for eligibility research.

Could not determine eligibility. Please call the insurance company to verify eligibility. The member (patient) needs to contact the payer to resolve issue(s) before this transaction can be completed: [specific error message].

Cause: A factor of the patient's policy is preventing the eligibility transaction from being processed correctly.
Solution: Call the payer to ascertain eligibility status; call the patient to communicate policy issue (some plans require a PCP to be selected before allowing eligibility checks, some plans have issued the same member ID/certification number to multiple patients, preventing an eligibility check).

Rendering and/or usual provider is not enrolled for electronic eligibility. Please call the insurance company to verify eligibility (provider: [specific provider]).

Cause: Provider does not have the necessary provider-level or group-level submitter ID for this intermediary.
Solution: Call the payer to ascertain eligibility status; log the issue with the CSC for enrollment services research.

Electronic eligibility checking with this insurer is not currently available for the provider. The payer requires a provider number or unique identifier to be enrolled for checking patient eligibility. Please call the insurance company to verify eligibility (provider: [specific provider]).

Cause: Provider does not have the necessary payer-assigned number needed for completing a transaction loaded in athenaOne.
Solution: Call the payer to ascertain eligibility status; provider may consider credentialing with the payer.

Electronic eligibility checking with this insurer is not currently available for the provider. Please call the insurance company to verify eligibility.

Cause: Provider's intermediary submitter number is not correctly enrolled at intermediary; these issues are addressed in a nightly script that fixes such enrollments.
Solution: Call the payer to ascertain eligibility status; enrollment issue will be corrected by athenahealth eligibility and enrollment staff.

Electronic eligibility checking with this insurer is not currently available for the provider. Please call the insurance company to verify eligibility (provider: [specific provider]).

Cause: Provider is correctly enrolled, but the provider number on file is invalid at the payer.
Solution: Call the payer to ascertain eligibility status; log the issue with the CSC for enrollment services research.

Electronic eligibility checking with this insurer is not currently available for the provider. The payer requires an extra number in addition to the provider number to be used for checking patient eligibility. Please call the insurance company to verify eligibility (provider: [specific provider] missing [pnc name or number missing]).

Cause: Additional payer-assigned number required.
Solution: Call the payer to ascertain eligibility status; log the issue with the CSC for enrollment services research.

Electronic eligibility checking with this insurer is not currently available for the provider. The payer requires a tax ID to be enrolled for checking patient eligibility. Please call the insurance company to verify eligibility (provider:[specific provider]).

Cause: Tax ID number is missing from the medical group associated with the provider.
Solution: Call the payer to ascertain eligibility status; consider loading a Federal Tax ID Number for the group if one is available.

Electronic eligibility status not available. This is due to incorrect or missing patient information such as the member ID, patient name, DOB, and SSN. Please check that this information is accurate, update the patient's records, and resubmit request. If this message persists, please call the insurance company to verify eligibility.

Cause: Some data element required by the payer is missing or invalid.
Solution: Call the payer to ascertain eligibility status; verify member ID/certification number, name spellings, DOB, and SSN and make any corrections to the patient insurance. If all information is correct at the payer, log the issue with the CSC.

The date of service specified is outside the payer's allowable inquiry period.

Cause: The DOS specified on the patient insurance page is older than the payer system can accommodate.
Solution: Call the payer to ascertain eligibility status; eligibility cannot be checked electronically for this DOS.

The date of service specified is in the future, which is not allowable by the payer. Please correct the Eligibility DOS and try again.

Cause: The DOS specified on the patient insurance page is in the future.
Solution: Call the payer to ascertain eligibility status; eligibility cannot be checked electronically for this DOS.

The payer is not responding to this eligibility request. Please try again later.

Cause: The payer or intermediary was down when eligibility was checked.
Solution: Try checking eligibility again — payer systems are often down overnight when the nightly sweep runs but become available during the day. If the payer is still not responding, call the payer to ascertain eligibility status and log the issue with the CSC.

The payer has indicated a delay in processing this eligibility request. Please check this account later for updated eligibility information.

Cause: The payer is not currently able to respond, but the transaction has been queued until payer is available again.
Solution: Check the patient's Quickview after a few minutes to get the response; if no response is received after 15 minutes, call the payer to ascertain eligibility status and log the issue with the CSC.

Electronic eligibility status is not available, please call the insurance company to verify eligibility.

Cause: Generated when electronic eligibility is not offered by athenahealth or by the payer.
Solution: Call the payer for eligibility information.

Electronic eligibility information is not provided for this product by the payer's eligibility system. Please call the insurance company to verify eligibility.

Cause: Generated when electronic eligibility is not offered by athenahealth or by the payer.
Solution: Call the payer for eligibility information.

Electronic eligibility status is not available for this insurance package. Please call the insurance company to verify eligibility.

Cause: Patient is not registered with the correct BCBS package, generating an error from the payer.
Solution: Call the payer for eligibility information. Make sure to register the patient with the correct package. If in doubt, contact the CSC by selecting Support > Create Case or Call in the Main Menu.

Electronic eligibility could not be completed because this patient has no rendering or usual provider assigned. Please call the insurance company to verify eligibility.

Cause: Appointment provider must be MD/DO to be used; if not, the eligibility check uses the usual provider. This message is generated if no usual provider is available and the scheduled provider will not suffice.
Solution: Select a usual provider for the patient and click "check eligibility."

Could not determine eligibility. Please call the insurance company to verify eligibility.

Cause: Error does not fall into our general guidelines and must be researched manually.
Solution: Call the payer to ascertain eligibility status; log the issue with the CSC for eligibility research.

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