Eligibility

Artisan has the ability to run eligibility for patients’ insurances to see if there is valid coverage for the insurance policy. This information pulls from the Change Healthcare Clearinghouse. 

Please Note: we recommend using the eligibility feature to make sure there is active coverage for a policy and to check the current accumulations for deductibles and out of pocket maximums. The eligibility response will not provide detailed information related to infertility coverage on most policies. We recommend reaching out to the insurance payer for detailed coverage information.

Eligibility Setup

Navigation

1. Click System Settings (gears) icon.

2. Hover over EMR Settings. Another menu will appear.

3. Select Manage Payers.

**Only Clinic Admin user privileges will have access to the Manage Payers selection.

This will open the Manage Payers section.

Find the insurance you want to add to Eligibility and click the pencil icon.

Enter the Eligibility Payer ID as provided by Change Healthcare in the Eligibility Payer ID field. Please note: this ID may not be the same as the payer ID. Please visit https://payerfinder.changehealthcare.com/ to search for Eligibility payer ID numbers.

Click Save to save the details for that payer.

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Using the Change Healthcare Payer Finder

Visit https://payerfinder.changehealthcare.com/

1. Click Advanced Search

2. In the Service Name filter, select Eligibility

3. In the Line of Business filter, select Medical

1. In the search bar, type the name of the insurance or part of the insurance’s name. For Blue Cross Blue Shield insurances, you may want to search by the state for an easier search response.

2. Use the Payer ID of your choice for that specific insurance. If there are several responses for that specific payer then select one. Select which ID you want to use in the Artisan Manage Payer section.

In the Artisan Manage Payers section, enter the Eligibility Payer ID and click Save.

Some insurance payers will not have Eligibility Payer ID numbers on the Change Healthcare Payer Finder website. You can try and use the same Payer ID number for claims in the Eligibility Payer ID field. Please know that while this may work for some insurances, it is not guaranteed for all insurances not having eligibility payer IDs.

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Set-up Appointment Types to Run Automatic Eligibility

You can set up appointment types to run eligibility 48 hours prior to the patient appointment. We recommend using the automatic eligibility for New Patient Consultations, surgeries, egg retrievals, and embryo transfers appointment types.

Navigation

1. Click System Settings (gears) icon.

2. Hover over EMR Settings. Another menu will appear.

3. Select Appointment Type.

Find the appointment you want to run automatic eligibility and click the pencil icon.

In this example, we selected the New Patient Appointment.

Click the Check Eligibility checkbox.

Click Save.

In this example, patients scheduled for a New Patient Appointment will have their eligibility run 48 hours prior to the scheduled appointment. 

Please Note: This feature is not retroactive and does not apply to previously scheduled appointments.

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Eligibility Status in the Appointment Calendar

For appointment types where automatic eligibility is processed, when a patient appointment is opened in the Appointment Calendar the eligibility status will display.

This eligibility status will allow the front desk team to determine if updated insurance is necessary from the patient if an Inactive status appears for Eligibility. 

In the above example, the patient has active insurance coverage for UnitedHealthcare.

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Manually Running Eligibility for a Patient

Eligibility can be manually pushed by a user for patients to determine if insurance is active, or to obtain up to date accumulations for deductibles and coinsurance.

Navigation

1. Click on the Accounting navigational tool.

2. Select the Patient tab.

3. Search for the patient you want to update eligibility on.

4. Click the Insurance Info tab.

5. In the Verification of Benefits box, select the Check Eligibility box.

1. Select Primary, Secondary, or Tertiary. Using the dropdown, select the appropriate insurance you want to run eligibility for

2. Click Check Eligibility.

The above popup will appear. Click OK.

Once the eligibility is processed, you will see a banner appear in the bottom right-hand corner notifying you that the response was either successful or if there are any errors.

To see the details of the eligibility response, click on the ‘i’ icon in the Verification of Benefits header to view the Eligibility Log.

The eligibility log provides users with a history of each eligibility run, whether automatic or manual.

1. Insurance Company - lists the insurance company used for that eligibility response.

2. Requested On - date and timestamp of when eligibility was requested.

3. Insurance Type - displays either primary, secondary, or tertiary payer.

4. Type - displays that the eligibility report was for the patient or partner.

5. Result - this area will show if the insurance is active, inactive, or if there is an error with the response from the clearinghouse or insurance.

6. Request - allows users to see the information sent to Change Healthcare regarding the patient or partner’s insurance.

7. Response - the data sent from Change Healthcare which provides details on the patient or partner’s benefits.

Results Reasons

	This result directs users to reach out to the insurance company directly for benefit information.  An example is an employer group, for instance, a union, using Aetna for claims processing purposes but not for eligibility.
	This result usually displays when a primary provider is not set up for the patient.  Clicking on the error, provides details of what needs to be updated to run eligibility.  (see 2nd image)
	This insurance is no longer valid.  New insurance information will need to be obtained.
	There is active insurance coverage for patient or partner for this policy
	The eligibility payer ID needs to be entered into the Manage Payers section of Artisan.

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Request 

The Request allows users to see the information sent to Change Healthcare regarding the patient or partner’s insurance.

The Response

 The Response displays the data sent from Change Healthcare which provides details on the patient or partner’s benefits. 

Please Note: The response will pull information for the patient/partner that is not just specific to infertility. We recommend using the CONTROL+FIND feature, CTRL+F [Windows] or COMMAND+F [iOS/Apple] to narrow down the necessary information.

In the above example:

1. The Control+Find feature was used to search for the deductible.

2. Service Type Codes - you will want to make sure that the Service Type codes for the benefits are ‘30’ which is the Health Benefit Plan Coverage. 

3. Time Qualifier - this will change depending on the benefit being searched such as Deductible Remaining or the Year to Date (amount met), in addition to other services. In this example, the time qualifier allows users to see if the plan runs on a calendar or plan/service year.

Benefits Amount - displays the amount of the deductible

In Plan Network Indicator Code - users can see if this benefit is for in or out of network services.

Benefits Date Information - shows effective date of patient/partner’s policy.

**The information from the Response can then be entered into the Verification of Benefits form in the Insurance Info tab.

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Eligibility Tab

The eligibility tab will display a log of all patients where eligibility was run, either manually or automatic, for the patient or partner. 

1. In Accounting, click the Clinic tab.

2. Select Eligibility.

3. Use the Sort and Filter options to filter: 

• Patients by Name
• Patients or Partners
• Eligibility Date range. 

Click the Search button. 

Clicking on the name of the patient will bring you into their Insurance Info tab.

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**All manuals are compliant with HIPAA regulations.  No patient information has been released.  All screenshots above were taken from a test clinic with fake patient information.