Real-time Eligibility Guide - Setting up Payers for eligibility checks (Paid Add-On)

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Overview

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What is Real-time Eligibility?

Real-time Eligibility (RTE) in Elation EHR enables you to request a patient’s primary and secondary insurance eligibility, coverage, and benefits based on the insurance details in their demographics. This article explains how to configure Carriers (Payers) in your EHR to ensure you receive insurance eligibility and benefits information. 📖 RECOMMENDED READING Click here to learn more about Elation’s Real-time Eligibility feature and how to use it .

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Setup

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Sending credentials & eligibility enrollment details to Elation

Elation must assist with completing Provider registration and eligibility enrollments before you can start using the Real-Time Eligibility feature. To begin this process:

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Updating Insurance Eligibility Settings

By default, the Real-time Eligibility feature uses the NPI of the Provider assigned in practice to run eligibility checks. If your practice is contracted with any payers using a Group NPI then you must add those Group NPI(s) to the Insurance Eligibility Settings to configure running eligibility checks using the Group NPI. You can add as many Group NPIs as needed. To add Group NPI information for eligibility checks:

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Updating Carrier Settings

Two fields in the Insurance Carrier details are required for eligibility checks: Eligibility Payer ID and Submitter Type. Please review these fields for each Carrier and make appropriate changes as needed to ensure successful eligibility responses.

• Additional Details - Eligibility Payer ID
  • The Eligibility Payer ID field stores the ID required (as designated by the Payer) to run eligibility checks for a specific payer. Click here to find the Eligibility Payer ID for a Payer.
• Credentialing & Enrollment**- Submitter Type**
  • The Submitter Type allows you to specify whether an Individual Provider NPI will be used to run eligibility checks or whether one of the Group NPIs will be used to run eligibility checks.
    • If Credentialed as a group is selected and you have multiple Groups, an additional dropdown will appear to allow you to select which Group will be submitted for eligibility checks.

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Adding Eligibility Payer ID and setting Submitter Type for each Payer

Follow the steps outlined in the quick video below to add the Eligibility Payer ID and set the Submitter Type for each Payer. You will need to have two windows or two tabs open in your web browser- one for Elation EHR and the other for ClaimMD’s Payer List (ClaimMD is the Clearinghouse Elation uses for eligibility checks). You can also follow the steps below, as demonstrated in the video above.

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Checking for eligibility enrollment requirements

Certain payers require you to complete a special enrollment process in order to obtain eligibility information. To verify whether a payer requires eligibility enrollments:

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Workflow Instructions

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Maintaining your Carrier list

Depending on how your organize your Carriers, you may have multiple entries for the same Carrier. Make sure the Eligibility Payer ID is populated for all entries of the same Carrier in order for eligibility checks to run properly. Here is an example of a list of Aetna Carriers and how the Eligibility ID field may look:

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Adding new Carriers

When you are about to add a new Carrier to your Carrier list:

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Adding new Providers

When adding a new Provider to your practice, you must notify Elation to complete their registration process so eligibility checks can be run for that Provider’s patients. To notify Elation:

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Troubleshooting Common Errors

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Incorrect Payer ID selection

Selecting the wrong Eligibility Payer ID is a common cause of eligibility check failures.

• Using a commercial payer ID for a Medicare product: Some payers use different Payer IDs for their commercial plans versus their Medicare Advantage products.
  • For example, UnitedHealthcare’s commercial plans may have a different Eligibility Payer ID than AARP-branded Medicare Advantage plans offered through UnitedHealthcare. Always confirm the correct Payer ID for the specific product your patient is enrolled in.
• Using a generic payer ID when the payer has distinct IDs for eligibility versus claims: Some payers have separate Payer IDs for eligibility checks and claims submission. The Eligibility Payer ID stored in your Carrier record must match the ID designated for eligibility, not claims.

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Patient has active coverage but the eligibility response says ‘inactive’ or ‘invalid’

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If eligibility checks still fail after updating the Payer ID

If you continue to see failures after confirming and updating the Eligibility Payer ID, contact Elation Support and include the following details:

• Payer name
• Payer ID currently configured in Elation
• Example Patient IDs and dates of failed eligibility checks

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Provider NPI has not been enrolled for eligibility with payer

If you see the following error when performing Eligibility checks- ‘Provider NPI [] has not been enrolled for eligibility with payer []’, this could mean one of the following: Payer ID does not support real-time eligibility. Invalid payer name… If you see the following error when performing Eligibility checks - ‘Payer ID … does not support real-time eligibility. Invalid payer name…’, this could mean one of the following:

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Frequently Asked Questions

What NPI information is used for an eligibility check? The NPI information used for an eligibility check will depend on the following:

• If a patient’s insurance carrier has Credentialed as a group listed under Submitter Type, then the Group name and Group NPI configured in the Insurance Settings will be used for both manual and automatic eligibility checks.
• If a patient’s insurance carrier has Credentialed as individual providers listed under Submitter Type, then the name and NPI of the patient’s Provider assigned in practice will be used for both manual and automatic eligibility checks.

How often do I need to update Carrier Settings?

The Eligibility Payer ID rarely changes for a Payer. If you are notified of a change in the Payer’s Eligibility ID then update the Eligibility Payer ID in Carrier Settings . The Submitter Type typically only changes when you change how you are contracted with a Payer. You can update the Submitter Type as needed. I have a Clearinghouse through my billing software. Is Elation connected to my Clearinghouse? Elation’s Real-time Eligibility feature is powered by Elation’s connection to ClaimMD. Elation is not connected to your Clearinghouse, even if your Clearinghouse is also ClaimMD.

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Related Articles

• Real-time Eligibility Guide - Checking for patient’s insurance eligibility in real-time
• Patient Demographics Guide
• Patient Demographics Guide- Managing patient insurance