Checking Insurance Eligibility (US-only)

The insurance eligibility check feature is a part of the US insurance claiming functionality in Zanda. It enables users enrolled with APEX to verify insurance coverage for clients. This articles provides a breakdown of how to perform these checks, interpret the results, and manage insurance eligibility within Zanda.

In this article:

Setting Up Insurance for Eligibility Checks

Batch Eligibility Checks for Upcoming Appointments

Running an Eligibility Check for a Single Client

Understanding Eligibility Check Response

Viewing Eligibility Reports

Handling Invalid Client Data

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Setting Up Insurance for Eligibility Checks

1. Enroll with APEX: Accounts must be enrolled with Apex to access eligibility checks, claims, and payments.
2. Setup Client Insurance: On the client’s billing setup, add the insurance details as usual. Once done, an additional eligibility information field will be available on the grid.

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Batch Eligibility Checks for Upcoming Appointments

With Zanda, you are able to run eligibility checks for all clients with upcoming appointments:

1. Navigate to Sales > Insurance > Eligibility
2. Filter the period of Upcoming Appointments: Today, Tomorrow or the Next 7 Days 
   • All clients with active insurance and an upcoming appointment according to the filter you have selected will be shown
     
3. Select all or some of the clients
   
   
4. Click “Run Check for Selected Clients” 
   
   
5. Click “View” under Actions to check results
   • Results will appear once processed, with a detailed report available for deeper insights.
     

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Running an Eligibility Check for a Single Client

Beside the batch eligibility check, it is possible to check eligibility of individual clients insurances.

Here is how:
1. Navigate to Client Profile >  Billing > Insurance.
2. In the Actions column, click the gear icon and select 'Eligibility Check'
3. Choose the appropriate coverage type from the list before running the check.
   
    
4. Submit the Check: Click 'Run Check'. First, the system performs validation to confirm all required fields are complete. If all fields are validated, the check will be submitted.

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Understanding Eligibility Check Response

• Unavailable: The payer does not support electronic eligibility checks.
• Queued: The check is submitted and waiting for a response.
• Requested: The check is submitted to APEX but awaiting response.
• Eligible/Ineligible: Confirmation of coverage status.

Each check result will appear in the client’s eligibility history for easy reference.

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Viewing Eligibility Reports

• Detailed Reports: A full eligibility response report will be accessible by selecting View in the eligibility table, which provides all details returned from the payer.
  • Via the Eligibility Report: Navigate to Sales > Insurance > Claims > Eligibility and after running the check click “View” under Actions to view the report 
  • Via the Client’s Insurance: Navigate to the client profile > Records > Insurance > After running the check click “View” under Actions to view the report

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Handling Invalid Client Data

If required fields are missing or data is invalid, the system will return an error, such as Invalid Client Data. To resolve:

1. Review Client Profile:
   • Navigate back to the client’s profile.
   • Correct the missing or invalid data based on the error message.
2. Re-run the Eligibility Check to confirm data is valid