Reading eligibility results

Eligibility checks ask the payer electronically whether the patient has coverage. For a visit, in the left sidebar, click Visits, then click the visit. In the visit section menu, click Insurance and use the Eligibility card to run a check, review the latest result, or open the full detail panel.

A compact eligibility badge can also appear in visit and patient lists and in the patient detail sidebar.

How do I open eligibility details for a visit?

In the left sidebar, click Visits, then click the visit. In the visit section menu, click Insurance.

In the left sidebar, click Visits, then click the visit. In the visit section menu, click Insurance.
Find the Eligibility card.
Select Check eligibility if no check has been run yet.
Select View eligibility details to open the full result.
Select Recheck if you need a fresh payer response.

While a check is running, the action reads Checking…. After a recheck finishes, the button briefly reads Checked. If the patient's insurance is incomplete, Ona shows a red inline block instead of the result, and Recheck stays disabled until the insurance changes.

How do I read the eligibility verdict?

On the visit's Insurance section, use the eligibility panel's coverage result as the quick answer. When the panel also shows a Coverage row, that row is payer coverage only; the overall result can also include script or prior authorization problems.

Verdict	What it means
Eligible	Payer coverage is eligible, and no authorization issue is shown for the patient.
Authorization issue	Coverage is unknown or not electronically verified, but a script or prior authorization needs attention.
Covered, authorization issue	Payer coverage is eligible, but a script or prior authorization needs attention.
Not covered by payer	The payer response says coverage is not eligible.
Not covered + authorization issue	The payer response says coverage is not eligible, and an authorization issue is also present.
Coverage unknown	The payer response did not determine coverage.
Verify with payer	The payer does not support electronic eligibility checks. Coverage is unknown, not denied.
Check failed	The payer or eligibility service rejected or could not complete the check.

Compact badges use shorter labels, such as Eligible, Auth Issue, Ineligible and Unknown. When insurance is incomplete, the panel shows a red blocked state instead of a retriable check, and Recheck stays disabled until the insurance changes.

How do I read the summary details?

On the same page, the summary area tells you what the check was based on and when it was retrieved.

Look for these fields:

Copay shows the copay summary at the top of the panel before the rest of the summary rows. It can read as a plan copay or a one-visit copay, and the caption can say Copay read for … when Ona tied it to a specific benefit.
Coverage shows payer coverage: Eligible, Ineligible or Unknown.
Svc code is the service type code used for the eligibility inquiry.
Checked shows when the result was retrieved, with the date plus how old it is or that it is stale. If no check has run, it reads Never.
Valid until appears when the result has an expiration date.
DOB, Plan and Group can appear when the panel is showing a check without the patient's insurance section in view.

If the panel shows summary notices, read those before relying on the figures. If the patient's insurance details changed, select Recheck to ask the payer again.

How do I review the insurance on file?

On the same page, use the Insurance section in the eligibility panel to confirm the plan details connected to the patient.

Each insurance card can show Member ID, Payer ID, Plan, Group, Insured and Relationship. Relationship appears when the insured person is not Self.

The first insurance is treated as the patient's primary coverage. Select Add to add another insurance. If you remove the primary insurance while another insurance remains, the next insurance becomes primary.

For more detail on maintaining patient coverage, see Patient insurance and card scanning.

How do I read scripts, prior authorizations and authorization warnings?

On the same page, use Scripts & Auths in the eligibility panel when coverage depends on a script or prior authorization.

The section separates active authorizations from ones that are out of date. Each card shows whether it is a Script or Prior-auth, the number when one is recorded, the valid date window when available, and can also show a case label and billed units. When visit-count details are present, the card also shows visits left, used and scheduled. If no counter is available, it shows No visit counter.

If Ona finds a problem, the panel shows an Authorizations warning. The warning can say:

Over its visit limit
Visits scheduled after it ended
Over its visit limit and past its end date

Select View authorization when it appears to jump to the matching script or prior authorization card. Use Add to record a new script or prior authorization.

For the full authorization workflow, see Managing prior authorizations.

How do I read benefit rows?

On the same page, the Benefits section shows the benefit rows returned by the payer. If no check has run, the panel says Benefits appear once a check has run. If a check has run and the payer returned no rows, it says The payer returned no benefit details.

The benefit area groups rows into collapsible sections by service code. Use the search box to find a benefit, note or code, and use the In network, Individual and This visit chips to narrow the list. Select Reset or Clear filters to clear the filters.

Each group header shows the service code and row count, plus a short summary like copay, coinsurance, not covered or auth required when the payer returned one. Open a group to read the rows inside it.

Each benefit row can show:

Code and Coverage code for the service type and benefit line.
Coverage for the kind of coverage or benefit.
Benefit for the benefit category.
Level for the benefit level returned by the payer.
Period for the time period returned by the payer.
Network for the network value returned by the payer.
Insurance type for the plan type when returned.
Notes for payer text that does not fit another field.

Read Level and Network before quoting a number. A family amount is not the same as an individual amount, and an out-of-network amount may not apply to an in-network visit.

What should I do when a check fails?

On the same page, when the eligibility panel shows Why the check failed, read the payer's reason before rechecking.

For payer rejections, Ona shows the reason in plain language and keeps the payer's wording and AAA code visible. The message may ask you to check the member ID, patient name, date of birth, subscriber details, payer, provider NPI or billing address. The panel also shows tailored copy when the check cannot run because insurance is incomplete, and for a too-long billing name it adds an Open billing settings link.

Read the failure reason in Why the check failed.
Compare the patient and insurance details with the card.
Correct the insurance or patient details if needed.
Select Try again in the failure notice, or Recheck in the panel header.

If the message says the payer is temporarily unavailable or did not respond, try again later. If the insurance is incomplete, fix the insurance first; Recheck stays disabled until that changes.

What does Verify with payer mean?

On the same page, Verify with payer means the payer does not support electronic eligibility checks. Coverage is unknown, not denied.

The panel does not show Recheck for this state. Verify coverage directly with the payer. Claims for that payer are submitted as normal and settle once you enter the payer's EOB by hand.

Ona cannot store the outcome of a phone eligibility check in this panel. Record what the payer tells you on the patient's chart.

What can't I do here?

On the visit's Insurance section, eligibility results have these limits:

You cannot recheck a payer marked Verify with payer from this panel.
You cannot recheck while the patient's insurance is incomplete.
You cannot store the result of a phone verification in the eligibility panel.
You cannot see benefit details the payer did not return.
You cannot edit the eligibility history or benefits-verification records from this panel.

Common questions

Why does the panel say there is an authorization issue when coverage is eligible?

On the visit's Insurance section, the eligibility panel can combine payer coverage with scripts and prior authorizations. Check the Coverage row for payer coverage alone, then read the Authorizations warning to see what needs fixing. If the patient's insurance is incomplete, the panel blocks the check until that is fixed.

What does the service type code mean?

Svc code is the service type code used for the eligibility inquiry. It tells you what type of benefit the payer was asked about.

Why are there no benefits?

On the visit's Insurance section, if no check has run, the panel says Benefits appear once a check has run. If a check has run and the payer returned no benefit rows, it says The payer returned no benefit details.

Can I add insurance from the eligibility panel?

Yes. In the visit's Insurance section, use Add in the Insurance section. You can also edit or remove insurance from that section.

Can I add a script or prior authorization from the eligibility panel?

Yes. In the visit's Insurance section, use Add in Scripts & Auths. Choose Script or Prior-auth, then record the number, visit counts and valid dates as needed.

What happens when a check fails?

On the visit's Insurance section, Ona shows the payer's reason in the red failure notice. Some payer rejections include AAA codes, and some app-side problems show tailored copy like The patient's insurance is incomplete or Your organization's legal name is too long. For the billing-name case, Ona also shows Open billing settings.

What does the copay label mean?

A plan copay is the amount Ona read from the payer for the patient's visits, while a one-visit copay applies to only one visit. The caption Copay read for … tells you which benefit Ona used to read the copay.

What does the Checked line mean?

Checked shows the retrieval date and how old the result is. When the check is older than a week, Ona marks it as stale so you know to recheck before relying on it.

Where did the benefit list go?

The benefits are grouped into collapsible sections. Use the search box and filter chips at the top of the Benefits area, then open the group you want to read.

Where do the history entries show up?

Eligibility history and benefits-verification records appear in the panel as read-only history content. They help you review what changed, but you update the underlying insurance or copay records elsewhere.