Inovalon - Eligibility Checks
- Dylan Nigh
This article covers how to make Eligibility Requests in the Inovalon portal. To do this, you’ll simply need your Claims Management Pro credentials to log into the Inovalon CMP Portal here:
https://providercloud.inovalon.com/
This article presumes that you have set up your Entities Table and completed enrollments with your payers as described in the Inovalon Payer Enrollment Guide. If you haven’t already, we strongly recommend that you review the process in the Payer Enrollment Guide and complete that, as it will be necessary when making Eligibility Requests.
Please be aware that there is a price per eligibility check of $0.20 as of the time of this writing (08-28-2024). This cost may change in the future, so be aware that there is a price per eligibility check. This applies to both methods to check eligibility for patients.
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 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.”
Creating Eligibility Requests requires three steps:
Selecting an NPI
Selecting Payer(s)
Entering in Patient and Request Information
First, you’ll select your NPI from the available ones listed, as shown in the image below. Please note that if your NPI is not present, you can click the “Add or Edit NPIs” link in the lower right corner of the NPI selector to make changes if this is necessary.
Selecting the Payer
Once you’ve selected the NPI, you’ll be brought to the Payer selection area:
When you first enter this area, all available Payers will be in the “All Payers” section, and as you begin to make Eligibility Checks, your top 15 frequently used payers will be populated in the “Top Payers” section there for easy access.
You can also use the “Search payers by name” field to search for a specific payer in the list, as there are over a thousand payers that you can create eligibility checks for. We recommend that you be specific in your searches, especially in cases like with “Medicare”. Entering the state will probably lead to better results in locating the correct payer.
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 from the payer.
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.
On the left hand side where you see “Subscriber Search by” lists different sets of criteria for which to identify a patient and submit an Eligibility Request for. You’ll need to select one of these sets to complete the fields for.
Each set will have a different list of fields that need to be completed. Any fields marked with an asterisk are required.
So in the example above for Medicare, we’ve selected a set of criteria that includes the Member ID, the Subscriber First and Last Name, and the Subscriber DOB. All these fields are required. If you didn’t have the DOB for this patient, you’d want to select a different set of criteria that you can complete all the fields for.
You’ll also note that in the above example, there is a restriction for which service dates you can select, viewable in the upper right corner under “Quick Date Pick”. This particular payer only allows you to select service dates 48 months back and 4 months ahead. Each payer can be wildly different in this regard, so be mindful of what’s listed in this spot.
From this screen, if you have multiple patients with this payer that you’d like to check eligibility for, you can click the “Add Patient” button in the lower right to add these. You can add up to 15 patients at a time.
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”.
When you click on an Eligibility Request, you should see the following screen:
In the above example, you’ll note that under “Your Request”, you’ll see the essential details of the Eligibility Request. Any fields highlighted in red indicate that the payer has returned data for that field that doesn’t match the request. In this example, we see that the DOB doesn’t match. In this situation, we’d want to verify the DOB with the patient and update that DOB in MacPractice if necessary to make sure your records are correct.
Updating a Request for Follow Up
In the upper right hand corner, you can see timestamp when the Response was generated, and the “Eligibility State” for the patient in question. In this example, we can see that the patient has Active Coverage. In this section, you can shift the Eligibility Request over to a different Inovalon user should you want another user to review the request, and you can mark it “Currently Unreviewed” for the other Inovalon users in your account to be aware of this request’s current administrative status. There’s also different Follow Up Statuses that you can assign, should you choose to use these. In the above example, we could check the “POatient Demographics” as an area to follow up on. You can also add this request to a batch of requests in order to group together logical sets of requests for better management.
If you make any changes to these settings in this section, you’ll need to click the “Update Request” button to complete those changes. Once you’ve clicked this, you’ll see a confirmation at the top of the view:
Viewing Coverage Sections
On the left side of the Request view, you’ll see this pane informing you of which sections are being displayed currently for this Eligibility Request. This view can be customized on a User basis AND on a Payer basis. You can save a particular view for particular use cases, such as if you’re only interested in certain kinds of coverage for procedures that your office covers, or a particular provider covers.
You can adjust what’s displayed by clicking the “Edit Display” button, or you can simply choose to show or hide all sections as needed. Adjust this to your office’s needs, and then you can scroll down to view these sections.
As you scroll down, you’ll see the different areas for Service Coverage Overview and any other sections which you set to display. This information is provided by the Payer, and is not edited by Inovalon. On the initial view, you’ll see a high level view of whether particular services are covered or not under the patient’s plan.
If you need to get more detail, you can click on the Details link to review those items.
There is also a section for User notes, and Payer notes. The User Notes can be used for intra-office communication to keep your staff informed on any circumstances regarding this Eligibility Request. You can also add notes for the Payer that’s selected, providing an excellent place to highlight any payer-specific information that the user should be aware of.
Typically, your overall co-pays and remaining coverage amounts will be listed under the Health Benefit Plan Coverage section.
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:
Or you can access these from the Patients Menu:
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.
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”.
Clicking “Responses” will take you to a list of Eligibiilty requests issued from this method:
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.
