Insurance eligibility verification

Purpose

1.1. Instantly verify client insurance eligibility during ABA therapy client onboarding, streamlining intake, reducing errors, confirming coverage, and accelerating access to therapy services.
1.2. Reduces manual insurance portals navigation by staff, enhances data accuracy, and automates communication of eligibility status for quick follow-ups.
1.3. Records responses, pre-authorizations, benefit limitations, required documentation, and alerts case management if additional info is needed.

Trigger Conditions

2.1. New client leads submit intake/contact forms via web or mobile.
2.2. Intake staff enters insurance info in EHR or CRM.
2.3. Scheduled calendar onboarding/new patient appointment detected.
2.4. Referral from physician with attached payer/insurance info.

Platform Variants

3.1. Availity
• Feature/Setting: Eligibility & Benefits API, configure payer endpoints with client identifiers.
• Example: Configure payer, provider NPI, member ID, and DOB in Eligibility request.
3.2. Change Healthcare
• Feature/Setting: Real-Time Eligibility API, configure x12 270/271 transactions.
• Example: Set up real-time eligibility transaction with payer code and insurance group.
3.3. Office Ally
• Feature/Setting: Eligibility Verification Web Service, configure with account credentials, provider NPI, and payer info.
• Example: Call eligibility endpoint and parse insurance response for coverage details.
3.4. SimplePractice
• Feature/Setting: Integrated Insurance Eligibility, configure to auto-run patient checks upon record creation.
• Example: Enable auto-eligibility check in client onboarding workflow.
3.5. Kareo
• Feature/Setting: Eligibility API, setup with API keys, provider, and payer info.
• Example: Initiate eligibility check triggered by new client record.
3.6. TherapyNotes
• Feature/Setting: Insurance Data Import, eligibility auto-verification toggle.
• Example: Turn on new patient insurance check in client profile workflow.
3.7. Athenahealth
• Feature/Setting: /insurance/eligibility endpoint, configure webhook on patient intake.
• Example: Use Athena API to query payer eligibility upon new client entry.
3.8. Epic
• Feature/Setting: Open.epic FHIR InsuranceEligibility resource; subscribe via FHIR events.
• Example: Trigger eligibility check on Patient resource creation with insurance details.
3.9. Cerner
• Feature/Setting: HealtheIntent Eligibility API endpoint.
• Example: Configure API with client/member demographic data at onboarding.
3.10. PracticeSuite
• Feature/Setting: Eligibility Verification Tool, schedule checks for new clients.
• Example: Auto-verify eligibility on patient import.
3.11. AdvancedMD
• Feature/Setting: Insurance Eligibility API, automates x12 270/271 requests.
• Example: Configure batch eligibility for group intakes.
3.12. Zendesk Sell
• Feature/Setting: Webhook integration to trigger eligibility API on new lead form.
• Example: Build automation that posts insurance data to eligibility checker.
3.13. Salesforce Health Cloud
• Feature/Setting: External Services setup with eligibility API; flow triggers on new record.
• Example: Map intake form fields to insurance verification service in Flow Builder.
3.14. Salesforce Experience Cloud
• Feature/Setting: Custom Lightning Component for real-time insurance eligibility.
• Example: Place component on client self-service onboarding page.
3.15. Greenway Health
• Feature/Setting: Insurance Eligibility Batch Processing.
• Example: Set to run scheduled eligibility on intake files.
3.16. eClinicalWorks
• Feature/Setting: Partner API Eligibility Verification, connect via SFTP for batch.
• Example: Intake triggers eligibility file upload and parse return file.
3.17. DrChrono
• Feature/Setting: Insurance Eligibility Check trigger, configure for auto run at patient add.
• Example: Setup workflow to ping payer on client creation.
3.18. Qualifacts
• Feature/Setting: Behavioral Health EHR Eligibility, setup with payer directory.
• Example: Configure on intake screen to auto-check coverage.
3.19. Allscripts
• Feature/Setting: Payerpath Eligibility Module, triggered from schedule.
• Example: Configure to check upon new appointment booking.
3.20. Practice Fusion
• Feature/Setting: Real-Time Eligibility Tool, set up on new patient entry form.
• Example: Enable auto-run for ABA Therapy tag in intake form.

Benefits

4.1. Instantly confirms insurance validity, decreasing onboarding delays.
4.2. Minimizes human entry errors and verification bottlenecks.
4.3. Flags authorization needs, coverage limits, and reduces denials.
4.4. Enables seamless documentation for audits and quality assurance.
4.5. Enhances client experience by reducing administrative wait times.
4.6. Real-time feedback to staff for proactive outreach.