Eligibility and Benefits (E&B) Verification

Overview

The Eligibility and Benefits (E&B) Verification feature in the zHealth software allows practices to check a patient's insurance coverage, plan status, and benefit details before services are rendered. This feature helps reduce claim denials, improve front-desk efficiency, and ensure accurate patient financial responsibility. Benefit details are retrieved electronically in real time directly from supported payers.

Using this EBV feature, practice staff can verify:

1. Insurance eligibility and active coverage
2. Plan type and payer details
3. Covered services and visit limitations
4. Deductibles, co-pays, and coinsurance
5. Authorization and referral requirement
   

To enable and configure the Eligibility and Benefits (E&B) Verification feature in your zHealth system, contact support at support@zhealthehr.com

Accessing Eligibility & Benefits (E&B) Verification

Once the E&B Verification feature is enabled in the system, the practice can initiate eligibility transactions and also view previously verified patient insurance eligibility and benefits from multiple screens. 

Before initiating an E&B Verification request, the practice must verify that the following details are properly configured in their zHealth system.

Insurance Setup: Correct Payer ID Configuration

All insurances in the zHealth Insurance Master must have the correct Payer ID linked to ensure E&B Verification requests are sent to the correct payer.  If already present, check and verify the Payer ID before submitting the request.

Ensure that the insurance for which the practice is sending the Eligibility Verification request has a Claim MD Payer ID linked. To do this, navigate to the "Insurance tab", click the "Edit" icon next to the payer name, go to the "Claim MD Payer ID" field, and enter the payer name or payer id. It will populate the payer details in the dropdown list. Select the correct payer from the dropdown to link it. Note: This is a one-time setup and needs to be completed only once before sending an E&B Verification request to the payer. The Claim MD Payer ID field will be available only when the Eligibility and Benefits (E&B) Verification feature is enabled in your system.

E&B Verification: Required Information

To initiate an Eligibility and Benefits (E&B) Verification request from the zHealth system, the practice must ensure that the required information is available in the patient's file, along with other additional details mentioned below:

1. Insured/Patient Last Name
2. Insured/Patient First Name
3. Payer ID to identify which payer to send the EV request to
4. Patient Relationship with the Insured
5. DOS: Service Date
6. Provider/Practice NPI
7. Provider/Practice Tax ID
   

In the zHealth system, a new "Check Eligibility" button has been added throughout the platform, allowing practices to initiate and run new Eligibility and Benefits (E&B) verification transactions.

Scheduled Appointment: On the appointment calendar, clicking a scheduled appointment (or the gear icon in the daily view) opens a modal window that has a new blue "Check Eligibility" button.

Primary/Secondary/Tertiary Insurance: In the patient's file/chart, the user can navigate to the "Contact Details" tab, open the "Primary/Secondary/Tertiary Insurance" sub-tab, enter the payer, then click the green "Check Eligibility" button to initiate the transaction.

Patient Billing: Within the patient's file/chart, the user can navigate to the "Patient Billing" tab, where a new green "Check Eligibility" button is available. Clicking this button initiates the Eligibility and Benefits (E&B) verification transaction.

Billing Centre: In the zHealth system, a new "Check Eligibility" button has been added to the "Billing Centre" page. Practices can use this button to initiate Eligibility and Benefits (E&B) verification transactions. Note: When clicking the "Check Eligibility" button in the "Billing Centre", the practice must search for and select a patient. This allows the system to automatically pull the required information from the patient's file to initiate the E&B Verification request.

E&B Verification: Run Eligibility Transaction

When the practice clicks the "Check Eligibility" button from any of the screens outlined above, a modal window opens with certain fields pre-populated based on the information available in the system.

1. The "Patient Name" field is automatically populated from the patient's file. If needed, the practice can click "Switch Patient" to search for and select a different patient.

2. When this modal screen is opened from a scheduled appointment, the Billing Centre, or the Patient Billing tab, the "Primary Payer" is selected by default in the "Payer Name" field. The user can change the insurance to a "Secondary or Tertiary Payer" (if active and available in the patient's file) to initiate the Eligibility and Benefits verification request for that payer.  The greyed-out field next to the "Payer Name" field is automatically populated with the Payer ID mapped to the insurance. If this field appears blank, it indicates that the Payer ID is not mapped. In this case, navigate to the "Insurance Master" and add the correct "Claim MD Payer ID" required to initiate the E&B verification request. Note: The Payer Name field displays only the patient's currently active insurances (primary, secondary, or tertiary). To run an Eligibility and Benefits verification for an inactive insurance, the practice must temporarily activate the insurance and then initiate the E&B verification request.

3. The "Provider Name" field displays a dropdown list of available providers or practices for the user to select from. This field may display either an individual provider (Individual NPI) or the practice name (Group NPI), depending on what is configured in the system/claim md clearinghouse. Note: Not all active providers or practices (Individual or Group NPIs) in the zHealth system will necessarily appear in the "Provider Name" dropdown when opening the "Check Eligibility" modal. Only providers or practices that are configured in the Claim MD clearinghouse will be displayed in the "Provider Name" field dropdown.

4. The "Patient Search Criteria" field is automatically populated from the patient's file/chart based on the insurance selected in the "Payer Name" field on the "Check Eligibility" modal window. Self/Dependent Member ID Patient Name

5. The "Service Type Code" field, also known as "Benefit Type", is set by default to "30- Health and Benefits". However, the practice can select a different benefit type from the dropdown menu, such as "33- Chiropractor", which is commonly used by chiropractic practices. Note: Most payers do not respond to the Procedure Code and only recognize the Benefit Type.

6. The "Date of Service" field defaults to the current date, but the user may select a past date if needed. Note: Future dates are not allowed.

7. Click the green "Verify Eligibility & Benefit" button to initiate the transaction. The process typically completes within a few seconds. Once successful, the user will receive a confirmation message and can view the E&B Verification details. If it fails or encounters any issue, it will throw an error message.

View Eligibility & Benefits (E&B) Verifications

Once an E&B Verification transaction is completed or if the practice needs to review a previously verified eligibility for a patient, the practice can click the "View Eligibility" button. This button is available throughout the zHealth system alongside the "Check Eligibility" button described above.

Scheduled Appointment: On the appointment calendar, clicking a scheduled appointment (or the gear icon in the daily view) opens a modal window that has a new blue "View Eligibility" button.

Primary/Secondary/Tertiary Insurance: In the patient's file/chart, the user can navigate to the "Contact Details" tab, open the "Primary/Secondary/Tertiary Insurance" sub-tab, enter the payer, then click the green "View Eligibility" button to initiate the transaction.

Patient Billing: Within the patient's file/chart, the user can navigate to the "Patient Billing" tab, where a new green "View Eligibility" button is available. Clicking this button initiates the Eligibility and Benefits (E&B) verification transaction.

Billing Centre: In the zHealth system, a new "View Eligibility" button has been added to the "Billing Centre" page. Practices can use this button to initiate Eligibility and Benefits (E&B) verification transactions. Note: When clicking the "View Eligibility" button in the "Billing Centre", the practice must search for and select a patient. This allows the system to automatically pull the required information from the patient's file to initiate the E&B Verification request.

E&B Verification: View Past EV

When the user clicks the "View Eligibility" button, a modal window opens displaying all past Eligibility and Benefits (E&B) verifications for the patient.

1. The "View Eligibility and Benefits (E&B)" pop-up screen includes the following features: Date of Request Filter: Allows the practice to apply a date range based on the E&B verification transaction date, displaying only eligibility checks performed within the selected period. Select Insurance: Enables the practice to filter E&B verifications by a specific insurance plan associated with the patient’s record.

2. All past E&B verifications (including the currently selected one) are displayed in a tabular format with the following details: Request ID: A unique identifier associated with each E&B verification transaction. EV Date: The date on which the E&B verification request was initiated. Payer Name: The name of the payer to whom the eligibility verification request was sent. This value is sourced from the Insurance Master, based on the payer name entered by the practice. Member ID: The patient’s insurance member ID. Plan Start–End Date: The insurance coverage effective dates returned directly by the payer during the eligibility and benefits verification process. Service Type: The type of service for which eligibility was verified. Status: Indicates whether the E&B verification transaction was successful or failed. Verified By: The name of the user who initiated the E&B verification request. View: If the verification is successful, a PDF icon is displayed, allowing the user to view the detailed benefits information received from the payer. If the verification fails, an error icon is shown. Clicking the icon displays the error details returned by the payer. Note: If no filters are applied, the system will display all E&B verifications performed for the patient across all insurance plans on file.

3. Successful E&B verification requests display the detailed benefits information received from the payer, as shown in the image here. Note: All information displayed here example insured patient details, insurance information, and benefit details, is received directly from the payer.

4. Failed E&B verification requests display the detailed error message as shown in the image here.

Payer Enrollment Requirement for E&B Verification

Yes, some payers require the practice and/or provider to complete enrollment before submitting E&B verification requests. For more details, check out our "Payer Enrollment for Benefit Verifications" help article.

If you have any questions, please feel free to contact zHealth Support at support@zhealthehr.com

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