Reading eligibility results

An eligibility check asks the payer, in real time, whether this patient is covered. Ona sends a 270 request and stores the 271 response, then shows you the result as a badge on the patient record.

Where the result appears

The patient header carries an eligibility badge — Insurance Eligible, Ineligible, or Unknown. The same badge appears in the Insurance column of the Visits list, so you can scan a day's visits for coverage problems before anyone arrives.

Click the badge to open the Eligibility Check panel.

The summary

• Status — the overall result, e.g. Eligible.
• Coverage — whether coverage itself is active. Status and coverage are separate fields, and they can disagree.
• Svc code — the service type code the check was run for, e.g. 30 (Health Plan). This comes from the benefit type codes set on the service.
• Checked — when Ona retrieved this result.
• Valid until — when it expires. In the example, checked Jun 25 and valid until Jul 25.

The Valid until date matters more than it looks. An eligibility result is a snapshot of what the payer said on a given day, not a standing guarantee. Coverage can lapse mid-month. If a result is close to expiring, or the visit is well after the check, re-run it rather than relying on the badge.

Insurance on file

The Insurance section shows each policy, with Primary and the payer name on the tab:

• Member ID — the patient's ID with this payer.
• Payer ID — the payer's identifier in the clearinghouse network.
• Group — the group number from the card.
• Insured — who holds the policy. This differs from the patient when a child is on a parent's plan.

Use Add to record a second policy where a patient has secondary coverage.

Scripts & auths

Prior authorizations and scripts attach here. When empty it reads "No scripts or auths yet — add one". If a payer requires authorization before a service, record it here so it's available when the claim is built.

Benefits

This is the parsed 271 response, and it can be long — 72 entries in the example. Each block shows what the payer said about one benefit:

• Code and Coverage code — the service type and what kind of benefit line this is.
• Coverage — e.g. Active Coverage, Deductible, Co-Payment.
• Benefit — e.g. Health Benefit Plan Coverage.
• Insurance type — e.g. C1 · Commercial.
• Level — e.g. FAM · Family or individual.
• Period — e.g. 24 · Year to Date.
• Network — whether the figure is in or out of network.
• Notes — free text from the payer, e.g. "FUNDING TYPE = FULLY INSURED".

Amounts appear on the right of the block header, so a deductible line shows the dollar figure directly.

Two things worth knowing when reading these. Level and Network change what a figure means — a family deductible is not an individual one, and an out-of-network copay is not what an in-network patient pays. And payers vary in how much detail they return, so a sparse benefits list reflects the payer's response, not a fault in Ona.

When a check fails

An Ineligible or Unknown badge usually means one of: the member ID or date of birth doesn't match the payer's records, coverage has lapsed, or the payer didn't respond. Check the details on file against the patient's card first — a transposed digit in the member ID is the most common cause.