Insurance verification and benefits checks

Purpose

1.1. Automate “Insurance verification and benefits checks” for incoming clients during adult foster care intake.
1.2. Eliminate manual verification, reduce errors, speed up onboarding, and ensure eligibility before providing services.
1.3. Facilitate real-time status checks, eligibility confirmation, benefits details extraction, and compliance logging for audit purposes.
1.4. Integrate returned data into EHR, care management portals, and CRMs for downstream workflows.

Trigger Conditions

2.1. New client intake form submitted by staff, prospective client, or referral partner.
2.2. Update on insurance policy data in the client’s EHR profile.
2.3. Scheduled periodic re-verification (e.g., every 3 or 6 months) for active clients.
2.4. Automated alert received of policy expiry or change via webhook or API.
2.5. Bulk upload of client census for mass verification.

Platform Variants

3.1. Experian Health
• Feature/Setting: Real-Time Eligibility API; configure with payer, member ID, DOB.
3.2. Change Healthcare
• Feature/Setting: Eligibility & Benefits API integration; specify payer codes and data mapping.
3.3. Availity
• Feature/Setting: Provider Portal e-Eligibility API; configure NPI, insurance details, and outcome endpoint.
3.4. Waystar
• Feature/Setting: Insurance Discovery API; automate batch eligibility checks with periodic triggers.
3.5. Office Ally
• Feature/Setting: Eligibility Verification (X12 270/271); auto-request upon client intake.
3.6. PokitDok (Change Healthcare)
• Feature/Setting: /eligibility endpoint; configure with insurance payer connection and patient fields.
3.7. Health Gorilla
• Feature/Setting: Patient Eligibility Checks API; fetch full benefits profile JSON with Minimal Demographics.
3.8. Corestream
• Feature/Setting: Benefits Verification API; specify indexing fields and define return mapping to client systems.
3.9. Salesforce Health Cloud
• Feature/Setting: Health Cloud Insurance Plan Verification Flow; automate with Flow Builder and REST API post.
3.10. athenahealth
• Feature/Setting: /patient/insuranceverification endpoint; set up webhook triggers for completed checks.
3.11. NextGen Healthcare
• Feature/Setting: EDI 270 Batch Eligibility Processing; configure SFTP drop folder and notification trigger.
3.12. eClinicalWorks
• Feature/Setting: Insurance Eligibility API (external payer); map intake form directly to eligibility payload.
3.13. Kareo
• Feature/Setting: Eligibility Checking Tool auto-triggered by client appointment creation.
3.14. PracticeSuite
• Feature/Setting: Patient Insurance Eligibility Endpoint; periodic scheduled runs with result sync.
3.15. SimplePractice
• Feature/Setting: Client Insurance Validation API; call check at client creation and before service.
3.16. Thryv
• Feature/Setting: Third Party Custom Integration to 270/271 Eligibility; webhook triggered from CRM intake.
3.17. CareCloud
• Feature/Setting: Insurance Eligibility Verification APIs; instant check at new patient registration.
3.18. Cerner
• Feature/Setting: PowerChart Eligibility Workflow automation with HL7 interface configuration.
3.19. Greenway Health
• Feature/Setting: Insurance Eligibility Web Service; incorporate into client onboarding protocol.
3.20. DrChrono
• Feature/Setting: Insurance Verification REST API; auto-send on intake form submission event.

Benefits

4.1. Completes insurance checks within seconds, eliminating manual data entry and error risk.
4.2. Ensures timely, financially sound client admissions.
4.3. Reduces denial risk and accelerates service delivery.
4.4. Centralizes eligibility logs for audits and compliance.
4.5. Improves staff productivity and satisfaction through automation.
4.6. Enhances client experience by reducing onboarding wait times.