Insurance eligibility verification prior to appointments

Purpose

1.1. Automates verification of patient insurance eligibility before pediatric nephrology appointments, reducing denied claims, improving billing accuracy, and saving administrative time.
1.2. Purpose includes real-time insurance data retrieval, comparison of plan coverage, co-pay/deductible identification, and pre-authorization flagging—creating an automated, compliant workflow for pediatric nephrology practices.
1.3. Automatedly notifies staff and patients of unresolved or ineligible status, avoiding manual error and accelerating appointment confirmations.
1.4. Supports compliance with regulatory standards by automating documentation and tracking of insurance verification processes.

Trigger Conditions

2.1. New pediatric nephrology appointment scheduled in EHR or calendar.
2.2. Update/correction entered for patient's insurance information.
2.3. Recurring batch runs on daily/weekly schedule for all upcoming appointments.
2.4. Manual trigger by billing or front-desk staff for ad-hoc verification needs.

Platform Variants

3.1. Cerner
• Feature/Setting: PowerChart API; automate insurance eligibility check on patient registration or schedule event.
3.2. Epic Systems
• Feature/Setting: App Orchard; automate eligibility via FHIR Endpoint /Coverage and /EligibilityRequest.
3.3. Allscripts
• Feature/Setting: Practice Management API; automates insurance verification using PatientEligibility endpoint.
3.4. Athenahealth
• Feature/Setting: Insurance Eligibility API; automation triggers on appointment booking.
3.5. Greenway Health
• Feature/Setting: Intergy API; automate eligibility check by scheduling event.
3.6. AdvancedMD
• Feature/Setting: Eligibility API; scheduled automation checks prior to visit.
3.7. DrChrono
• Feature/Setting: Insurance API; automates verification for new appointments.
3.8. Kareo
• Feature/Setting: EligibilityCheck endpoint; automated runs for all scheduled pediatric nephrology appointments.
3.9. Meditech
• Feature/Setting: Expanse REST API; automate eligibility pulled on patient event trigger.
3.10. NextGen
• Feature/Setting: Insurance Verification API; automates cross-checks pre-visit.
3.11. Change Healthcare
• Feature/Setting: Medical Network API; automates real-time eligibility calls.
3.12. Availity
• Feature/Setting: Eligibility and Benefits API; automates batch or real-time eligibility verification.
3.13. Experian Health
• Feature/Setting: Patient Access API; automatable batch eligibility verifications.
3.14. PokitDok (Change Healthcare now)
• Feature/Setting: Eligibility API; automate coverage checks per scheduled pediatric nephrology patient.
3.15. X12 EDI
• Feature/Setting: 270 Eligibility Request/271 Response; automate submission/processing for eligibility inquiries.
3.16. Office Ally
• Feature/Setting: Eligibility API; automated submit for pre-appointment checks.
3.17. TrueCred
• Feature/Setting: Eligibility Endpoint; automate eligibility data pulls before visits.
3.18. Salesforce Health Cloud
• Feature/Setting: Health Cloud API, automatedly triggers eligibility check on new Lead/Contact appointment.
3.19. Inovalon
• Feature/Setting: Eligibility and Benefits API; automates eligibility checks with payer network.
3.20. Zendesk (for notifications)
• Feature/Setting: Triggers/Automations; automate internal notification to staff about ineligible patients.

Benefits

4.1. Automates a historically manual, error-prone process—saving staff time and operational costs.
4.2. Automatedly identifies coverage gaps, reducing claims denials and increasing pediatric nephrology revenue.
4.3. Accelerates appointment confirmations and patient intake by automating timely insurance validation.
4.4. Reduces compliance risk and simplifies audits by creating automated, traceable verification logs.
4.5. Enhances patient experience by automating proactive ineligibility notifications and streamlined check-ins.