Eligibility and benefits re-check before each visit

Purpose

1.1. Automate real-time validation of patient insurance eligibility and benefits before each scheduled visit to ensure accurate coverage, identify potential gaps, and preempt billing denials.
1.2. Reduce administrative effort and manual errors in behavioral health billing for alcoholism treatment programs.
1.3. Alert staff of any discrepancies or changes in patient coverage, facilitating timely rescheduling or patient financial counseling.
1.4. Streamline claim submissions by ensuring benefit validation pre-authorization is secured before services are rendered.

Trigger Conditions

2.1. New appointment created or updated within EHR, practice management, or scheduling system.
2.2. Upcoming patient visit detected within specified lead time window (e.g., 48 hours, 24 hours).
2.3. Recurring eligibility check for patients with ongoing treatment.
2.4. Change or update in patient insurance data in the system.

Platform Variants

3.1. Epic (EHR)
• Feature: Automated Eligibility Verification
• Setting: Integrate Eligibility Verification API with scheduled appointment triggers.
3.2. Cerner
• Feature: nCode Eligibility API
• Setting: Configure Eligibility Query workflow within PowerChart module.
3.3. Athenahealth
• Feature: Eligibility Check API
• Setting: Link Practice Management eligibility endpoint on appointment create/update.
3.4. NextGen Healthcare
• Feature: Real-Time Eligibility Service
• Setting: Schedule eligibility requests via Practice Management Automation.
3.5. AdvancedMD
• Feature: Insurance Eligibility Check
• Setting: Trigger automated batch eligibility checks before each appointment.
3.6. Kareo
• Feature: Insurance Verification Tool
• Setting: Connect API endpoint for scheduled eligibility confirmation.
3.7. DrChrono
• Feature: Insurance Validation API
• Setting: Use Appointment Webhook to invoke eligibility lookup.
3.8. SimplePractice
• Feature: Automated Insurance Verification
• Setting: Enable recurring eligibility checks in client profile workflows.
3.9. OpenEMR
• Feature: x12 Eligibility 270/271
• Setting: Configure scheduled x12 batch runs via cron module.
3.10. Availity
• Feature: Real-Time Eligibility & Benefits API
• Setting: Integrate 270/271 submission and response via API scheduler.
3.11. Change Healthcare
• Feature: Eligibility Verification API
• Setting: Set up eligibility transactions linked to appointment triggers.
3.12. Experian Health
• Feature: Patient Eligibility API
• Setting: Configure daily or per-visit eligibility batch transactions.
3.13. HealthFusion/Waystar
• Feature: Eligibility & Benefits Verification
• Setting: Automate eligibility inquiry at appointment confirmation.
3.14. PracticeSuite
• Feature: Real-Time Eligibility Module
• Setting: Link appointment status to eligibility checker.
3.15. Meditech
• Feature: Claims Management APIs
• Setting: Schedule regular eligibility lookups via automation suite.
3.16. Google Cloud Healthcare API
• Feature: FHIR-based Eligibility Resource
• Setting: Scripted triggers to check insurance resource on each appointment.
3.17. Microsoft Azure Logic Apps
• Feature: Connector for Health Insurance APIs
• Setting: Automated workflow trigger with eligibility query at scheduled event.
3.18. Redox
• Feature: Eligibility Verification Integration
• Setting: Deploy Eligibility Check endpoint with polling or event-based triggers.
3.19. MuleSoft
• Feature: Health Insurance EDI Integrator
• Setting: Orchestrate scheduled batch 270/271 processing for every visit.
3.20. HL7 FHIR Servers
• Feature: CoverageEligibilityRequest
• Setting: Endpoint called programmatically per scheduled appointment.

Benefits

4.1. Reduces claim rejections due to eligibility/benefits errors.
4.2. Decreases administrative burden and staff intervention.
4.3. Lowers patient frustration from surprise billing and coverage issues.
4.4. Enables proactive patient engagement for financial counseling or coverage adjustments.
4.5. Improves revenue cycle management accuracy and speed.
4.6. Provides automatic audit trail for compliance and reporting.