At a Glance
Eligibility is the determination of a patient's qualification for healthcare services based on several factors including insurance coverage, benefits and provider network.
Eligibility checks will come back as Active, Inactive, or Inconclusive.
Inconclusive Eligibility Checks: Possible Causes
- Not all payers are supported. We do our best to address these issues by assigning our manual team to look up benefits. If you are still seeing inconclusive results, please flag it to us.
- Missing or malformed data. We occasionally receive data in unrecognizable structures, which then serves incorrect results. Please flag issues so we can find and fix them. We’re continually improving our eligibility results, so flagged errors are very helpful for us to optimize our system.
- Rules may be misfiring or missing. If a rule is too inclusive, it may trigger when it shouldn’t. Your account manager can help assess the scope of your practice’s rules.
- Bad mapping. Occasionally, mis-mappings will lead to inconclusive results. If you’re seeing repeated inconclusive results for a particular insurance, please contact your account manager.
Here’s How to Do It
For Patients With an Appointment
Find the patient’s appointment and click the listed insurance you’d like to check.
A modal will appear with eligibility details, as well as a note on the last update to this information in the upper right corner. Click Re-run to run another eligibility check.
If an eligibility check returns a status of inactive, you can contact the patient and update their information in your EHR and Athelas will update within 24 hours.
If you need it sooner, you can update their information BOTH in Insights on the Encounter Details page (guide available here) AND in your EHR.
For Patients Without an Appointment
Navigate to the Appointments page and click on Live Eligibility Check.
Fill in all required information, then click Check.
Note that it may take up to 30 seconds to see results.
In this example, we see an ‘Inactive’ eligibility result. The next step would be to contact the patient for their latest insurance information and make updates accordingly in your EHR. Athelas will pull the new information from your EHR within 24 hours.
❓Eligibility FAQs
Does Insights track visit limits?
Yes. Visit limits can be found in eligibility checks and within individual appointment details.
When are visit limits updated?
Our system tracks visit counts based on different events on Insights. This is how we calculate the remaining visits for a prior auth:
Claim Submissions
If there is a prior auth number on the latest claim submission on an encounter, we count a visit.
Checked-in Appointments
Any appointment with status CHECKED_IN, COMPLETED or ONGOING is counted as a visit.
Scheduled Appointments
Any appointments with status SCHEDULED or CONFIRMED. We show these, but don’t actually decrement since these are in the future. Note the light grey line on the timeline.
Manual Modifications
If users manually update the prior auth count. When this happens, we will show which user made this update.
Does Insights track benefit maximums?
There is a filter on the Denials page for Denial Reason: Benefit Maximum, so you can view all such current cases. This information is not currently surfaced on individual patient profiles.
Currently, Insights does not create a notification when a patient nears their benefit maximum.
Is there a notification for patients approaching their visit limit, or if there’s an issue?
Yes, but it is currently only shown with the rest of the eligibility information. You’ll need to run an eligibility check to view those details.
Once a claim is denied due to maxed benefits, is the patient automatically flagged so that the front desk can warn them?
Not as of March 5, 2025.
📢 Further Assistance
We’re here to help! Please get in touch with support@getathelas.com if you’d like some hands-on assistance.
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