Eligibility Verification

Eligibility Verification
Once enrolled for B2B Eligibility Verification through the MacPractice Enrollment Department, a username and password will be assigned from Change Healthcare. A MacPractice EDI Support Representative will assist in getting this information entered into the software. This information is located in the eClaims ability under Template Values on your ProxyMed template.

To submit eligibility checks, a default eClaims template must be set under References > Offices > Default Template. The MacPractice EDI Department can assist with getting this entered correctly.

Next, add the correct Change Heatlhcare Payer IDs entered for any insurance companies that an eligibility check will be run. A list of participating insurance carriers can be found on Change Healthcare’s Real Time Payer List from the URL below.

Eligibility Payer List

These Payer IDs can be placed under References > Insurance Companies in the Claims Payer ID field and/or Eligibility Payer ID field.

Note: If nothing is entered in the Eligibility Payer ID field, the system will look at the Claims Payer ID field.

If there is a plan set on the insurance reference, there are also fields for ‘Claims Payer ID’ and ‘Eligibility Payer ID’ under References > Insurance Companies > Plans > Demographic.

Next, the patient account will need to be checked for completion of required fields. Under the Patient tab of the Patients ability, the following fields must be set for a successful eligibility check: 

  • Default Office
  • Default Provider

Each patient will need to have his or her insurance set here. Correct the patient information in this window:

  • First and Last name
  • Address 
  • Sex
  • Social Security Number (SSN)*
  • Date of Birth*
  • Subscriber ID
  • Group Number (if applicable)*

* This item may or may not be required, depending on the payer.

From here, select the patient's insurance to be checked and click the ‘Check Eligibility’ button.

From the popover shown below, select the specialty type/type of service and click the ‘Submit/Next' button. Specialty type ‘Health Benefit Plan Coverage’ will return generic benefit coverage information. To quickly move to this option, press ‘H’ on the keyboard.
Note: Some payers do not offer eligibility for specialties or certain specialties, in which case they would return generic benefit coverage despite your specialty selection.

If checking eligibility for a Non-Medicare insurance carrier (based on insurance payer plan type under References>Insurance Companies>Claims), results page will display for the eligibility check after hitting the Submit button.

If checking eligibility for a Medicare carrier, a popover page for preventative care codes will be presented. Select from the list of Preventive Service (HETS Requirement for Medicare/CMS) procedure codes in order to run the check specific to those codes. The results will then contain details specific to the selected procedures.

Alternatively, clicking ‘Submit’ with no codes selected in order to continue with a generic search.

New Preventative Care Codes can be added under References > Eligibility Preventive Care Codes

After clicking ‘Submit’, the eligibility response is received in real time from Change Healthcare and the eligibility results will display in a separate popover window. The result report can be printed (Command + P) and/or saved as a PDF to import into attachments. Once viewed and/or printed, this window can be closed. 

After the results are closed, go into eClaims > Reports to find the .ELG file again to review it. The search field in the sidebar can be used to search for pertinent information on a report, such as patient name.

If any errors are received when attempting to check patient eligibility, check the following to confirm they are correctly set.

Under the Patient tab, the following must be set for a successful check:

  • Default Office
  • Default Provider
  • Insurance
    • Subscriber ID
    • Payer ID

Under the Patient/Primary/Secondary tabs, the insurance may require the following be set/entered:

  • Group #
  • Birth Date
  • SSN
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