Insurance Eligibility Verification

Eligibility Check

Navigation: Insurance → Eligibility Transactions

Checking Patient Eligibility

1. Go to the patient's Payer tab in their profile
2. Click "Check Eligibility"
3. Choose the request type:
   • Discover Request — Basic eligibility check (is the patient covered?)
   • Discover + Benefits — Comprehensive check including benefit details, limits, and copay
4. The system sends the request to NPHIES

Discover + Benefits Response

When using Discover + Benefits, NPHIES returns the patient's plan information. The system auto-populates:

• Plan name
• Relationship
• Patient Policy Number
• Issue Date, Active Date, Expiry Date

If the patient has multiple plans, the system shows all available options.

Eligibility Statuses

Status	Meaning
Eligible	Patient has active insurance coverage
Not Eligible	No active coverage found

Transaction Statuses

Status	Meaning
Completed	Transaction successful
Failed	Transaction not successful — retry or check details

Benefit Details

For approved eligibility, the system shows:

• Max Benefit Limit
• Max Patient Share
• Copay Amount
• Benefit Used

Eligibility Transaction List

Search past transactions by: Patient MRN, HIC Name, Patient Name, Date Range. Each transaction shows an Eligibility ID (unique identifier).

Common questions

How do I check insurance eligibility?

Run a NPHIES eligibility request — Discover, or Discover + Benefits — for the patient.

What is the difference between Discover and Discover + Benefits?

Discover confirms coverage; Discover + Benefits also returns the covered benefits.

When should I verify eligibility?

Before delivering care, to confirm the patient's insurance is active.