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There are two methods for checking Eligibility. Each of these methods has a different way of tracking the results of the Eligibility Check, and won’t show up in the other method’s tracking, should your office use both methods. The First method is better used for situations where you are checking eligibility ahead of appointments, while the second method is better served for more impromptu checks.

First Method - Making an Eligibility

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Request

On the front landing page when you log into Inovalon’s portal, you can create Eligibility requests by navigating to the “Front-end RCM” tab. This method will leave a history of these eligibility checks which you can refer back to as necessary. This is a great method to use when you want to check Eligibility in advance.

When you click it, you’ll see a list of options under “Eligibility Workflow”. Click on “Make an Eligibility Request.”

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When you select a payer, you’ll note that the payer selection mentions the number of Service Type Codes that are selected. These Service Type codes selected will detail coverage for that type. We definitely recommend ensuring Health Benefit Plan Coverage is checked.

You can click the Edit button to select more Service Type Codes from here. Please note that you can only select up to 5 from this view (but you can also adjust this from the Dashboard, which we’ll cover in the “Tracking Eligibility Requests” section later in this article.

Of importance, however, is the “Send each Service Type Code in a separate transaction” checkbox here. If this is checked, each service type code will be included in a separate transaction, as opposed to one transaction with multiple service type codes. This means if you have 5 Service Type Codes selected with that checkbox checked, 5 transactions would be sent and have to be trackedfrom the payer.

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Entering Patient Details

Once you’ve selected the payer, you’ll then be taken to Patient Details. Each payer can have different criteria for what information will be needed in here and different restrictions for service date selections, so this can look very different depending on which payer you’ve selected.

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Once you’ve added all your patients, you can click the Submit button to send this Eligibility Request.

Tracking Eligibility Requests using the First Method

This section applies to Eligibility Requests created using the First Method.

You can find your existing Eligibility Requests that were created by the First Method described above under the “My Dashboard” link under the “Front-end RCM” selection. You can also find your history of Eligibility Requests in the same place under “Eligibility Request History”.

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Typically, your overall co-pays and remaining coverage amounts will be listed under the Health Benefit Plan Coverage section.

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Second Method - Checking Eligibility in CMP

You can also check Eligibility directly in Claims Management Pro in the Back-end RCM section where most billers will be spending most of their time. This method is ideal for checking eligibility on the spot.

You can access Eligibility Requests and Responses from the Quick Links on the dashboard:

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Or you can access these from the Patients Menu:

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From here, the view can differ depending on whether this Payer is a Medicare payer or not.

When you select Eligibility Request, you’ll be taken to the following page, where you will need to select the Payer, and select search criteria for the Subscriber to identify the insured patient. Then, you’ll need to select the appropriate NPI and the subscriber details. Finally, you’ll need to set your Service Codes you’d like to get the details of coverage for. You can select up to 5 service codes.

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Once done, hit the Submit button.

Tracking Eligibility Requests using the Second Method

You can locate your Eligibility requests using this Second Method by clicking on the Patients Menu in CMP, and selecting “Eligibility Requests”.

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Clicking “Responses” will take you to a list of Eligibiilty requests issued from this method:

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If the eligibility request was successful, you should see a results page. This page will differ depending on whether the payer is a Medicare payer or not.

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