When an eligibility check fails
How 2care routes each kind of failed eligibility check, which ones retry on their own and what your staff do to clear the rest.
3 min read
Key terms
- Rejection. An answer from the payer saying the check could not be completed, with a standard reason code.
- Subscriber not found. A rejection meaning the payer could not match the patient's details to a member.
- Enrolment. Your provider's registration with a payer, tied to their NPI.
How rejections are routed
2care reads the payer's reason code and sends each failed check down the right path.
| What the payer reports | What 2care does |
|---|---|
| A patient detail does not match (name, date of birth, member ID) | Points your staff at the exact field to correct |
| The patient may be on the plan as a dependent | Retries once as a dependent |
| The payer's system is temporarily unavailable | Retries automatically after 15 minutes |
| A problem with the provider's NPI or enrolment with that payer | Opens one task and pauses checks to that payer for your practice until it is fixed |
The pause in the last row keeps your budget from going on checks that would all come back the same way. Once the NPI or enrolment is fixed, checks to that payer resume.
Patient not found
A "subscriber not found" answer usually means a small mismatch in the details. 2care gives your staff up to 3 suggested corrections, drawn from the most common causes:
- Swapped names. First and last name entered the wrong way round.
- Surname form. A hyphenated surname entered as a single surname, or the other way round.
- Date of birth. Day and month swapped.
- Member ID. A prefix or suffix added or left off.
Your staff pick the suggestion that fits, correct the record and the check runs again.
Payers without electronic eligibility
Some payers do not offer electronic checks. Visits with these payers are routed to your staff to confirm coverage by phone. They appear on the same list as everything else that needs a person.
Unknown and empty results
If a payer returns a status 2care does not recognise, the result reads as unknown, never as inactive. Your staff see it as something to confirm, and the visit stays on the books. If the payer did not send a copay or deductible, the field stays blank instead of showing zero.
Asking the patient for new insurance
When a result comes back inactive, or the card on file is more than a year old, 2care can text the patient asking for their updated insurance. This text is off by default, and your practice switches it on if you want it. Insurance a patient reads out on a call is saved as a draft for your staff to review.
Checklist for your team
- Read the reason. Open the visit and read the rejection reason shown with the check.
- Fix the field. If a field is highlighted, correct it in the patient record.
- Try a suggestion. If corrections are listed, use the one that matches what the patient told you.
- Call the payer. If the payer has no electronic eligibility, call and record the answer.
- Pass on enrolment tasks. If a task about your NPI or enrolment appears, send it to whoever handles credentialing.
Questions
Will a failed check cancel the appointment?
No. A failed or unknown result is shown to your staff to follow up. The appointment stays exactly as it was booked.
Do retries count against our budget?
Spend on checks stays inside the monthly budget your practice sets. Pausing checks to a payer with an enrolment problem keeps repeated rejections from using it up.
Who decides which plan pays first?
2care suggests an order and labels how sure it is. A member of your staff applies it. See eligibility checks before visits.
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