Eligibility checks before visits
When 2care checks your patients' insurance before a visit, what your staff see in each result and how you keep spend inside your budget.
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Key terms
- Eligibility check. A question sent to the patient's insurer asking whether their coverage is active and what they will owe.
- 270/271. The standard electronic request (270) and response (271) insurers use for eligibility.
- Clearinghouse connection. The link 2care uses to send each check to the right payer.
- Payer order. Which plan pays first when a patient has more than one.
How checks run
Eligibility checks are switched on for each practice during setup. Once they are on, the work runs in the background and your staff see the results.
- Sweep. Every hour, 2care looks for visits booked in the next 48 hours.
- Check. Each visit gets its own 270 request, sent through a clearinghouse connection.
- Result. The payer's 271 answer is saved against the visit for your staff.
- Re-check. If you choose, a second check runs closer to the visit.
Insurance from a call
Checks are sent from the background sweep only. When a caller reads out new insurance details on the phone, the agent saves them as a draft. A member of your staff reviews the draft before it is used.
Spend controls
| Control | What it does |
|---|---|
| Reuse | An answer is reused for up to 7 days, so a patient with two visits in one week is checked once |
| Monthly budget | Your practice sets a monthly budget for checks, and spend stays inside it |
| Per practice | Checks are switched on for each practice separately |
What the result shows
Each answer is stored as clear fields, not a block of payer text.
| Field | What your staff see |
|---|---|
| Coverage status | Active, inactive or unknown |
| Plan dates | The plan's start and end dates |
| Patient costs | Copay, coinsurance, deductible and out-of-pocket amounts |
| Other payers | Any other coverage the payer has on file |
Two rules keep each result honest. If the payer returns a status 2care does not recognise, it reads as unknown, never as inactive. If the payer did not send a value, such as a deductible, the field stays empty instead of showing zero.
Medicaid plans
Each result tells Medicaid fee-for-service apart from Medicaid managed care, using the insurance type and plan name the payer returns. Your staff see at a glance which kind of plan a patient is on. For patients with a renewal coming up, see Medicaid renewal outreach.
Payer order
When a patient has more than one plan, 2care suggests an order using a set of rules.
- Payer-stated order. The order the payer itself reports comes first.
- Federal rules. Next come the federal rules, including Medicaid paying after any liable third party and the Medicare Secondary Payer rules.
- Commercial rules. Commercial coordination rules apply after that.
Each suggestion is labelled Confirmed, Likely, Conflict or Needs answers, so your staff know how much checking it needs. The order is a suggestion only. A member of your staff applies it.
Exceptions
Some checks come back with a rejection, a patient the payer cannot find, or a payer that does not offer electronic eligibility. Each one is routed to the right fix or the right person. See when an eligibility check fails.
Questions
Does the agent check insurance during the call?
The agent collects the insurance details the caller reads out and saves them as a draft for your staff. The check itself is sent by the background sweep before the visit.
Which visits are checked?
Visits booked in the next 48 hours, for each practice where checks are switched on. Your onboarding specialist sets this up with you, along with the monthly budget.
Do patients hear about their check?
Only if you choose. An optional text asking for updated insurance is off by default. See when an eligibility check fails.
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