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HomeVerification of insurance eligibilityPatient Intake and OnboardingVerification of insurance eligibility

Verification of insurance eligibility

Purpose

1. Automate the process of verifying patient insurance eligibility prior to home health care onboarding to reduce manual workload, prevent service denials, increase accuracy, and improve patient experience.

2. Streamline data collection, automatedly submit verification requests, receive eligibility responses, and automate eligibility documentation for compliance and audit purposes.

3. Ensure rapid, accurate screening of patient insurance details for Medicare, Medicaid, commercial insurers, and managed care plans as part of automated patient intake via healthcare automation platforms.


Trigger Conditions

1. New patient intake form submitted via web, EHR, or call center.

2. Referral received from physician or hospital for home health services.

3. Patient self-registration event.

4. Batch scheduled daily for verifying eligibility of pre-filled referrals.

5. Manual trigger from case manager initiating patient onboarding automation.


Platform Variants

1. Salesforce Health Cloud

  • API: Health Cloud Patient Services API — automate insurance verification workflow via Flow Builder.

2. Microsoft Power Automate

  • Connector: Health Level 7 (HL7) FHIR API integration — configure trigger/action to automate eligibility checks.

3. Athenahealth API

  • Endpoint: /insurance-eligibility — configure automated call when new patient created.

4. Cerner Open Developer Experience

  • API: Eligibility Verification Service — automate eligibility request action on patient object creation.

5. Epic App Orchard

  • API: Coverage Eligibility API — configure automated eligibility query post-patient registration.

6. Change Healthcare

  • API: Real-Time Eligibility (RTE) — setup automator to send and receive eligibility responses.

7. Availity

  • API: Eligibility & Benefits — automate 270/271 EDI transaction for real-time checks.

8. Redox

  • Data Model: Insurance Eligibility — automate eligibility queries using Redox API integration.

9. Datica Integrate

  • Feature: EDI Transaction Automation — automate submit/receive of 270/271 eligibility inquiries.

10. Health Gorilla

  • API: Patient Eligibility API — configure event-driven automation for insurance checks.

11. TrueVault

  • API: Insurance Eligibility Verification endpoint — configure automated eligibility verification workflow.

12. Tines

  • Feature: HTTP Request Automation — automate POST request to insurer eligibility API on intake event.

13. Zapier

  • App: Webhooks by Zapier — automate eligibility API calls upon intake data entry.

14. MuleSoft Anypoint

  • Connector: Healthcare Eligibility Checks — automate end-to-end eligibility flow orchestration.

15. AWS Lambda

  • Trigger: API Gateway — automate insurance verification microservice on new patient registration.

16. Google Cloud Functions

  • Feature: Event-driven API automation — automate insurance check scripts connected to EHR submission.

17. InterSystems IRIS for Health

  • Endpoint: FHIR Insurance Eligibility — automate workflow to query and log eligibility responses.

18. NextGen Healthcare

  • Interface: Insurance Verification Module — automate eligibility requests on inbound referral.

19. Meditab

  • API: Real-Time Insurance Verification — automate event-based insurance eligibility status retrieval.

20. PointClickCare

  • API: Eligibility Verification — automate scheduled or event-based insurance status checks.

21. RPA Tool: UiPath

  • Activity: HTTP Request/EDI Integration — automate pulling and storing eligibility data from health plans.

22. Surescripts

  • Service: Electronic Prior Authorization & Eligibility — automate eligibility workflow via Surescripts integration.

Benefits

1. Automates and accelerates insurance verification, reducing intake cycle time.

2. Decreases manual data errors and duplicate effort via automation.

3. Automator ensures compliance with payer requirements through automatic documentation.

4. Automated eligibility checks help prevent billing denials and lost revenue.

5. Enhances patient satisfaction by minimizing wait time and friction through automatable onboarding.

6. Frees staff from repetitive tasks to focus on high-value patient care via automation.

7. Improves scalability for intake operations by automating eligibility step at any patient volume.

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