Direct Eligibility

Eligibility is the DNA of all healthcare transactions.  Many providers find out the hard way the patient’s insurance card is not definitive proof of eligibility. Most payer rejections are for patient not eligible for services.

The number one reason for rejected claims is invalid or incomplete subscriber information. This problem is solved by delivering critical eligibility data to your desktop in a matter of seconds. Eligibility responses not only show if a patient is eligible for service but it can also help in determining what you need to collect from your patients to cover co-payments and deductibles. There are several options for verifying eligibility:

Real Time Eligibility
Real time eligibility can be performed via an interface to the provider’s practice management system or using the Exchange EDI MedConnect real time web portal.  Either option allows the user to enter data according to the payers specific search criteria and within seconds receive a real time response to the eligibility request that is displayed in an easy to read format.  The response will display all the data that is returned from the payer or it can be parsed to show only the eligibility information for a particular specialty.

Batch Eligibility
The Exchange EDI Batch Eligibility service allows the user to send multiple requests to many carriers at one time for processing in a batch format. If a provider desires to confirm all patients’ eligibility prior to service, the batch service can be performed a few days in advance of the appointment. Using their practice management system, the provider will initiate a batch to be sent to Exchange EDI.  Once received, the batch is parsed into individual inquiry transactions.  The transactions are sent to the payers in real time.  Once received, the transactions are formatted back into a batch and routed back to the providers practice management system or to the Exchange EDI MedConnect portal.