Eligibility Verification

Eligibility verification ensures a patient has the necessary coverage before a service is performed. This section discusses more about verifying eligibility electronically and manually.

Viewing Eligiblity Information

After the eligibility is verified, the eligibility information appears in the following locations.

  • In the Dental Insurance section on the Patient Overview window, the icon indicates that eligibility has been verified, and the icon indicates that eligibility needs verification or that the insurance plan has expired. For example, in the following screenshot, the patient's primary insurance has been verified, but the secondary insurance is not verified or expired.

    You can hover over the Verified icon to view the date on which eligibility was last verified. If eligibility was verified electronically through EDI Clearinghouse, the EDI message regarding eligibility also appears when you hover over the icon. Both the Verified and Needs verification icons indicate when a carrier does not support real-time eligibility checks, when you hover over them.

  • Eligibility also appears on the Scheduler window when you hover over the insurance eligibility status icon in an appointment box.
  • In the list view of the Scheduler, the Last verified column displays the icon along with the last verified date. The icon will appears for unverified patients or if the insurance has expired. Last verifiedcolumn will appear blank for patients who do not have a carrier.
  • When you are adding or editing the insurance plan for a patient, the verification information for each family member appears in the Family Coverage section.

Eligibility Verification

Electronic and annual eligibility verification can be done using the following methods. The availability of these options depends on your practice setup and subscriptions.

  • Automatic verification of eligibility a set number of days before an appointment. This option requires each office to define the number of days prior to an appointment that verification occurs.
  • Electronic verification of eligibility, as needed.
  • Manual verification of availability by contacting the carrier and then noting the patient's eligibility in the application.

Verify Eligibility Electronically As Needed

Practices that subscribe to EDI Clearinghouse service can check eligibility electronically on an as-needed basis. An insurance eligibility report details the response from the carrier.
Note: Insurance last verified dates displaying in red indicate it has been greater then 30 days since an eligibility verification was performed.
  1. On the Patient Overview screen, click the eligibility icon (either Verified or Needs verification ) in the Dental Insurance section.

    The Patient Eligibility screen displays.
  2. Select Primary or Secondary or both to indicate which coverage will be checked. The far-right column of the Current Insurance Policies section indicates whether the plan is eligible for a real-time eligibility check.
    Note: To view details about a patient's primary or secondary insurance plan, click the plan ID.
  3. Click Check Eligibility.

    The system submits a request for an eligibility check and logs the request in the history in the lower half of the window. When a response is received from EDI, the result will appear in the history, and you will be able to view and print the eligibility report by clicking the link in the Report column. If applicable, the patient's status will also change to verified.

Verify Eligibility Manually

Once you have verified a patient's eligibility by contacting the carrier, you can note this in the system via the Patient Last Verified Date field.
Note: Insurance last verified dates displaying in red indicate it has been greater then 30 days since an eligibility verification was performed.

To mark a patient's insurance as verified:

  1. On the Patient Overview screen, click the Primary or Secondary link in the Dental Insurance section.
    The system displays the plan's details on the Add/Edit Dental Plan screen.
  2. In the Subscriber Information section, select the desired member subscriber if necessary.
  3. Click Insert Date Stamp next to the Patient Last Verified Date field.
    The system inserts the current date in the Patient Last Verified Date field.
  4. Click Save.