5.8. Verify Medical Insurance Eligibility

Verify Medical Insurance Eligibility

Medical Verify displays the real-time medical eligibility response received directly from the payer through TriZetto.

1. Open the patients Insurance information.

2. Select the applicable medical insurance and click Medical Verify.

3. Review the Active Coverage section.

The Active Coverage section displays the service types the payer is reporting as active.

For a medical office visit, review the applicable Professional (Physician) Visit Office service type.

If the service displays Active, the payer is confirming active coverage for that benefit category.

!IMPORTANT Active coverage confirms that the payer returned the benefit as active. It does not confirm the exact amount the patient will owe for the visit.

4. Review the Deductible & Out-of-Pocket section.

This section displays the deductible and out-of-pocket information returned by the payer. Depending on the payer response, this may include the benefit level, network status, year-to-date amount, remaining amount, and calendar-year amount.

5. Review the Co-Insurance section.

Locate the applicable Professional (Physician) or Professional (Physician) Visit Office service.

The Share column displays the coinsurance percentage returned by the payer.

For example, if the response displays 0%, the payer is reporting 0% coinsurance for that service.

6. Review the Co-Payments section.

The Amount column displays the copay dollar amount when the payer provides a specific amount in the eligibility response.

!IMPORTANT If the Amount field is blank, this does not mean the patient has a $0 copay. It means the payer did not return a specific copay dollar amount in the eligibility response.

7. Review the Limitations section.

Any benefit limitations returned by the payer will display in this section. If the payer does not return limitation information, the response will display No limitation information available.

8. Review the Non-Covered section.

Any non-covered service information returned by the payer will display in this section. If no information is returned, the response will display No information available.

!PRO TIP For a medical visit, use Medical Verify to confirm active medical coverage and review the office visit benefits, deductible and out-of-pocket information, coinsurance, and copay information returned directly by the payer.

!IMPORTANT Medical Verify displays the direct real-time eligibility response received from the payer through TriZetto. iTRUST does not calculate or generate the eligibility status, deductible, out-of-pocket amount, coinsurance, copay, limitations, or non-covered benefit information displayed on this page.