Automatic insurance verification and eligibility checks

Purpose

 1.1. Automate real-time insurance verification and eligibility checks for pediatric ophthalmology clinics.
 1.2. Automates extraction of patient insurance data upon appointment scheduling or intake form completion.
 1.3. Automates retrieval of insurance plan details and patient eligibility directly from insurers.
 1.4. Automator triggers requests to third-party payers, checks response for coverage, co-payments, deductibles, exclusions, and pre-authorizations.
 1.5. Automates notifications to staff and patients if coverage is denied or needs clarification, enabling rapid follow-up.
 1.6. Automates entry of verified insurance information into the electronic health record (EHR) to reduce manual errors.

Trigger Conditions

 2.1. Automating when a new patient appointment is scheduled in EMR/EHR.
 2.2. Automator watches when patient digitally submits intake or insurance information.
 2.3. Automation upon staff-triggered verification from EHR or PMS dashboard.
 2.4. Automates nightly batch checks for upcoming appointments.
 2.5. Automatedly activated via API when insurance details are updated by patient or received via patient portal.

Platform Variants

 3.1. Availity — Real-Time Eligibility & Benefits API
  • Feature/Setting: Automate API calls to /eligibility endpoint; configure patient demographics and group/policy numbers.
 3.2. Change Healthcare — Eligibility Verification Service
  • Feature/Setting: Automates POST to Eligibility API; enables X12 270/271 transaction mapping.
 3.3. Office Ally — Eligibility Request Interface
  • Feature/Setting: Automates transmission via SFTP/API; configures payer ID and enrollment key.
 3.4. Epic (EHR) — Insurance Verification Work Queue
  • Feature/Setting: Automator schedules auto-verification events in patient flow.
 3.5. Cerner (EHR) — Insurance Eligibility Check Automation
  • Feature/Setting: Configurable Cerner HealtheIntent query for real-time checks.
 3.6. Athenahealth — Automated Insurance Eligibility Rules
  • Feature/Setting: Enables EDI 270/271 transaction automation in admin portal.
 3.7. NextGen Healthcare — Eligibility Verification Automation
  • Feature/Setting: Background verification scheduling via NextGen Connect Integration Engine.
 3.8. DrChrono — API-Based Insurance Verification
  • Feature/Setting: Automates POST to drchrono.com/api/v2/insurance_verifications/ endpoint.
 3.9. Kareo — Automated Insurance Checks
  • Feature/Setting: Triggers automation in Kareo PM with configuration of verification cycles.
 3.10. eClinicalWorks — Auto Insurance Eligibility
  • Feature/Setting: Automates eBO custom report triggers for eligibility audits.
 3.11. Allscripts — Open API for Eligibility Checks
  • Feature/Setting: Automates call to FHIR Eligibility resource.
 3.12. SimplePractice — Automated Insurance Checks
  • Feature/Setting: Enables real-time eligibility with Availity/Eligible integration.
 3.13. Greenway Health — Insurance Eligibility Automation
  • Feature/Setting: Automates EDI 270/271 via automated nightly scheduler.
 3.14. Experian Health — Automated Insurance Verification
  • Feature/Setting: Automates API endpoint calls for instant eligibility data pull.
 3.15. Eligible API — Universal Verification API
  • Feature/Setting: Automates POST /v2/eligibility.json request with policy parameters.
 3.16. PokitDok — Benefits & Eligibility API
  • Feature/Setting: Automates POST to /eligibility for payer lookup and patient-level check.
 3.17. Medical Information Bureau (MIB) — Eligibility API
  • Feature/Setting: Automates secure API POST for policy validation.
 3.18. Health Gorilla — Insurance Data Exchange
  • Feature/Setting: Automates HL7 FHIR Insurance validation request.
 3.19. Salesforce Health Cloud — Automated Flows
  • Feature/Setting: Uses Flow Builder and Mulesoft connector for eligibility automation.
 3.20. Qvera Interface Engine — Automated Eligibility Workflows
  • Feature/Setting: Automator triggers X12 270 generation and response parse.

Benefits

 4.1. Reduces manual insurance verification efforts and administrative labor with automation.
 4.2. Increases accuracy by automating data pulls directly from payers and eliminates human input errors.
 4.3. Automates notification of coverage issues, reducing pre-appointment coverage delays.
 4.4. Ensures real-time access to eligibility decisions for staff and patients through automation.
 4.5. Streamlines patient intake workflow by automatedly populating verified insurance fields in EHR.
 4.6. Automates compliance with payer requirements and reduces rate of denied claims.
 4.7. Enables scalability—automator handles increased patient load without new staff.
 4.8. Frees up staff for higher-value tasks via automation of routine verification.
 4.9. Improves patient satisfaction through quicker eligibility confirmation by automating communication.
 4.10. Enhances revenue cycle management with timely, automated pre-visit eligibility checks.