Payer Enrollment for Benefit Verifications
Overview
Some insurance payers mandate that a practice or provider be formally enrolled or credentialed with them before any electronic transactions, including Eligibility & Benefits (E&B) verification, can be processed. This is to ensure that the provider/practice is recognized in the payer's system and is authorized to access patient insurance data.
Who Needs to Enroll?
- Practice/Clinic: Typically for group submissions or if the E&B requests are sent under the clinic’s NPI.
- Individual Provider: Required if requests are sent under the provider’s individual NPI or if the payer requires provider-level authorization.
Exceptions
- Not all payers require pre-enrollment; some allow verification requests from non-contracted providers, though results may be limited.
- Certain payers only enforce enrollment for specific plan types (e.g., Medicaid or Medicare Advantage).
Benefit Verification Payer Enrollment Process
If the E&B Verification feature is enabled in your zHealth system, on the Insurance Master page, a new column labelled "Eligibility" is available. This column indicates whether a Claim.MD Payer ID is mapped to the insurance. When a payer ID is mapped, it also identifies whether that payer requires enrollment before E&B verification requests can be sent.
For more details on mapping the Claim MD Payer ID: Insurance Configuration (E&B Verification)
 1. The "Eligibility" column displays the payer enrollment status for Eligibility and Benefits verification:
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| 2. When the user clicks "Enrollment", a modal window opens prompting the user to select the provider or practice (individual or group NPI) to enroll with the payer. This selection determines the entity under whose details the patient’s E&B verification request will be submitted to the payer. Note: The status of the enrollment will also be displayed. |
3. When the user clicks the green "Enroll" button, the enrollment instructions are displayed. Please review the instructions carefully and follow them as outlined to complete the required paperwork. 4. Once enrollment is successfully completed, the system will notify you. You will also receive updates if there are any issues from the payer. Note: Not all payers send enrollment progress status updates. |
.If you have any questions, please feel free to contact our support team at support@zhealthehr.com
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