Insurance verification and eligibility checks

Purpose

1.1. Automate insurance verification and eligibility checks to confirm patient coverage before processing lab tests, reducing claim denials, and accelerating revenue cycles.
1.2. Automating retrieval of insurance data ensures laboratory orders are submitted with correct payer details, minimizing manual errors and freeing staff for higher-value tasks.
1.3. Enable instant, automated cross-referencing of patient data with insurer databases for up-to-date eligibility status, facilitating automated decision-making in billing workflows.
1.4. Supporting automated pre-authorization where required, automating the retrieval and submission of documents to insurers.

Trigger Conditions

2.1. Automatedly triggered upon new lab order entry in Laboratory Information Management System (LIMS).
2.2. Automated scheduling (e.g., every morning) to pre-check eligibility for all scheduled patients.
2.3. Manually triggered by staff when order has incomplete insurance details.
2.4. Automated re-verification when changes detected in patient insurance records.

Platform Variants

3.1. Epic Systems (EMR)
- Feature/Setting: Configure automated HL7 interface and Eligibility API for real-time patient insurance checks tied to order entry events.
3.2. Cerner (EMR)
- Feature/Setting: Activate automated eligibility verification workflows via Cerner Revenue Cycle APIs.
3.3. Athenahealth
- Feature/Setting: Use Automated Benefits Verification API for real-time insurance validation.
3.4. Meditech
- Feature/Setting: Schedule eligibility batch checks using Meditech’s eClaims Eligibility Query.
3.5. Availity
- Feature/Setting: Automate with Availity Eligibility and Benefits API endpoint for coverage determination.
3.6. Change Healthcare
- Feature/Setting: Configure Real-Time Eligibility Verification API for automated requests and status captures.
3.7. Experian Health
- Feature/Setting: Use eCare NEXT automated eligibility verification module for batch or real-time checks.
3.8. Office Ally
- Feature/Setting: Enable Real-Time Eligibility Inquiry (270/271) tool for automated checks via their portal API.
3.9. NextGen Healthcare
- Feature/Setting: Setup automated eligibility check service linked to patient intake.
3.10. Kareo
- Feature/Setting: Activate batch and real-time eligibility verification integration for all new appointments.
3.11. Greenway Health
- Feature/Setting: Schedule automated eligibility checks through Greenway Intergy’s Eligibility functionality.
3.12. PracticeSuite
- Feature/Setting: Configure automated claims and eligibility check sequences via Eligibility Verification API.
3.13. AdvancedMD
- Feature/Setting: Activate eligibility verification automation in billing rules engine.
3.14. eClinicalWorks
- Feature/Setting: Utilize automated eligibility verification workflows triggered by appointment creation.
3.15. Allscripts
- Feature/Setting: Deploy Allscripts Real-Time Eligibility module for event-triggered verification.
3.16. Zirmed
- Feature/Setting: Configure eligibility batch processing via ZirMed APIs.
3.17. Instamed
- Feature/Setting: Schedule automated eligibility checks through the Real-Time API.
3.18. Quest Diagnostics
- Feature/Setting: Use interactive automated eligibility screens and HL7 API triggers for insurance validation.
3.19. LabCorp
- Feature/Setting: Enable automated eligibility checks by integrating with LabCorp’s Insurance Verification Service API.
3.20. Surescripts
- Feature/Setting: Automate eligibility via Surescripts Eligibility & Formulary API on patient registration.

Benefits

4.1. Automates time-consuming verification steps, reducing manual workload and increasing throughput.
4.2. Automating eligibility checks minimizes claim rejections due to coverage errors.
4.3. Accelerates billing processes through real-time, automated data integration.
4.4. Automated re-checks ensure up-to-date coverage for every patient encounter.
4.5. Enables scalable, error-reduced laboratory insurance processing with automated compliance documentation.
4.6. Enhances patient satisfaction by automatedly notifying them upfront if insurance issues detected.