Automated insurance verification and eligibility checks

Purpose

1. Automate the process of verifying patient insurance coverage and determining eligibility for abortion-related medical services, reducing manual workload, ensuring compliance, improving billing accuracy, and accelerating payment cycles.

2. Seamlessly access real-time data from insurers, provide staff with instant eligibility status, and pre-populate billing systems to minimize claim denials and delays in reproductive healthcare facilities.

Trigger Conditions

1. Patient appointment scheduling or check-in triggers verification.

2. Manual staff submission of new insurance details.

3. Routine pre-visit eligibility checks (e.g., 24–48 hours prior).

4. Patient update through web forms or patient portals.

5. Periodic batch process for upcoming appointments.

Platform Variants

1. Redox

• Feature: Eligibility API connection to payer networks; configure webhook for insurance verification lifecycle events.
  

2. Change Healthcare

• Feature: Real-Time Eligibility API; set up EDI 270/271 integration using client credentials.
  

3. Availity

• Feature: Eligibility & Benefits API; OAuth2 setup and payer endpoint configuration.
  

4. Experian Health

• Feature: Eligibility API; configure client ID, payer mapping, and callback URL for automated responses.
  

5. PokitDok (Pokit API)

• Feature: Eligibility endpoint; send X12 270 request via REST API for real-time coverage data.
  

6. Eligible API

• Feature: /v2.0/eligibility/check; set provider, member, and payer parameters for automated triggers.
  

7. Alphion Patient Eligibility

• Feature: Eligibility Verification module; automate API calls with patient and schedule triggers.
  

8. Emdeon (now Change Healthcare)

• Feature: Eligibility Service API; input subscriber/payer data and schedule automated verification.
  

9. Rectangle Health

• Feature: Integrated real-time insurance verification service; enable API calls on patient intake events.
  

10. TriZetto Provider Solutions

• Feature: Eligibility Verification API integration; map patient appointment events to API calls.
  

11. Waystar

• Feature: Eligibility Verification tool; connect API with daily patient registration batch uploads.
  

12. Vericred

• Feature: Payer Data API; automate the onboarding process for payers and eligibility checks.
  

13. Office Ally

• Feature: Eligibility Enquiry web services; configure automatic triggers on EMR interaction.
  

14. Brightree

• Feature: Automated Eligibility Verification; link to patient registration workflows.
  

15. Cerner

• Feature: Revenue Cycle API – Eligibility module; schedule eligibility checks at patient pre-registration.
  

16. Epic

• Feature: Eligibility Verification within Cadence; set up event-driven integration using Bridges.
  

17. Athenahealth

• Feature: Electronic Eligibility API; utilize HL7 trigger on patient creation.
  

18. Allscripts

• Feature: Eligibility and Benefits Check; automate EDI 270/271 transactions on schedule.
  

19. Greenway Health

• Feature: Prime Suite Eligibility Verification; map to insurance fields in patient chart.
  

20. Netsmart

• Feature: Eligibility API; connect to intake checklist automation for instant checks.
  

Benefits

1. Reduces manual entry and errors—ensures eligibility before service and billing.

2. Increases claim acceptance and decreases payment delays.

3. Enhances patient experience with transparent cost and eligibility info upfront.

4. Ensures HIPAA compliance and audit trail via digital logs.

5. Saves staff time, enabling focus on patient care in reproductive health.