Before you schedule a patient for treatment, you should verify the health care benefits that the patient is eligible for through their insurance payer. Verifying eligibility helps you avoid delays in getting payment for services that might not be covered.

Benefits provided by an insurance company to a patient are determined based on the provider and on the type of service provided. When you submit a benefits eligibility inquiry to the clearinghouse that processes inquiries for an insurance company, the clearinghouse returns a response that is uploaded to the DrCloudEHR database. When you check benefit eligibility for a patient, the application retrieves the information from the database.

The information in the database is typically valid unless unless the patient changes to a different provider or switches to another insurance carrier. When this happens, you can submit a benefit eligibility inquiry to the clearinghouse to retrieve the latest information, which is uploaded to the database. You then retrieve the latest information from the database.

Note that you might be charged a pay a fee when you submit a benefits eligibility inquiry to the clearinghouse.

This topic contains the following sections:

Verify Benefits and Eligibility for a Single Patient

You can verify benefits and eligibility provided by an insurance company to a patient when you:

  • Create a new encounter for the patient
  • When a you add the patient as an application for inpatient care
  • When you schedule an appointment for the patient

The application retrieves the benefits eligibility information for the patient from the DrCloudEHR database. If the patient's insurance coverage has changed, you can send a benefits eligibility inquiry electronically to the clearinghouse used by the patient's insurance company. 

  1. Click the Benefits button on the patient page. 
    The application displays the results of the request to retrieve data from the database in the table below. Click the icon in the Action column to view the information retrieved.
  2. Enter the following information:
    • Select the service category as defined by the insurance company from the Service Code menu.
    • Select the name of the provider/clinician providing treatment.
    • If you want to submit a benefits inquiry through the clearinghouse used by the insurance payer, select the name of the EDI connection to use from the X12 Partners menu.
    • Select the patient's insurance company and the provider providing treatment.
  3. The application displays the results of the request to retrieve data from the database in the table below. Click the icon in the Action column to view the information retrieved.
  4. If the patient's insurance coverage has changed, click Get Latest Benefits  benefits to submit an eligibility inquiry electronically to the clearinghouse. The application displays the results of the inquiry in the table below. Click the icon in the Action column to view the inquiry response from the database.

Verify Benefits and Eligibility for One or More Patients 

You can retrieve information on benefits and eligibility for one or more patients through the clearinghouse used by an insurance company. The application displays a list of selected patients with the status of the request to retrieve the patient's data.

If the insurance coverage for the selected patients has not changed, you can retrieve the information directly from the DrCloudEHR database. If the coverage has changed, you can submit a benefits eligibility inquiry to the clearinghouse to update the database with the latest information.

  1. Click the Billing tab.
  2. Click Eligibility & Benefits in the left hand navigation bar.
  3. Enter the following information:
    • Select the dates the inquiry requests were submitted. This information might be helpful if you want to view the status of requests made over multiple days.
    • Select the patient's insurance company and the provider providing treatment.
    • Select the service category as defined by the insurance company from the Service Code menu.
    • Select the patients you want to retrieve data for.
    • If you want to submit a benefits inquiry through the clearinghouse used by the insurance payer, select the name of the EDI connection to use from the X12 Partners menu.
  4. Select one of the following options to retrieve benefits data:  
    • Click Search from DB to retrieve the information directly from the DrCloudEHR database. Click the icon in the Action column to view the information retrieved.
    • If you you need to update the benefits eligibility data for a patient, click Generate Eligibility Benefits. 
      The application sends a displays a list of selected patients with the status of the request to retrieve the data.
      • Click the icon in the Action column for a patient.
      • Enter the details described in Verify Benefits Eligibility for a Single Patient. 
      • Click Get Latest Benefits to submit an eligibility inquiry electronically to the clearinghouse. The application displays the results of the inquiry in the table below. Click Click the icon in the Action column to view the inquiry response from the database.





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