At a Glance

Eligibility is the determination of a patient's qualification for healthcare services based on several factors including insurance coverage, benefits and provider network.

Eligibility checks will come back as Active, Inactive, or Inconclusive.

Our eligibility runs are service type based, and provide remit analysis and tailored recommendations for Copay, Deductible & Coinsurance

You can have PCP (Primary Care Provider) visibility for select payers

You can map appointments to relevant service types (e.g. office visits, physical therapy, mental health, etc.) by navigating to "PR Settings" —> "Appointment Rules"

Inconclusive Eligibility Checks: Possible Causes

• Not all payers are supported. We do our best to address these issues by assigning our manual team to look up benefits. If you are still seeing inconclusive results, please flag it to us.

• Missing or malformed data. We occasionally receive data in unrecognizable structures, which then serves incorrect results. Please flag issues so we can find and fix them. We’re continually improving our eligibility results, so flagged errors are very helpful for us to optimize our system.

• Rules may be misfiring or missing. If a rule is too inclusive, it may trigger when it shouldn’t. The Athelas account management team can help assess the scope of your practice’s rules.

• Bad mapping. Occasionally, mis-mappings will lead to inconclusive results. If you’re seeing repeated inconclusive results for a particular insurance, please contact your account manager.

Here’s How to Do It

For Patients With an Appointment

Find the patient’s appointment and click the listed insurance you’d like to check.

A window will appear with eligibility details, as well as a note on the last update to this information in the upper right corner. Click Re-run to run another eligibility check.

If an eligibility check returns a status of inactive, you can contact the patient and update their information in your EHR. Insights will update with the new information within 24 hours.

If you need it sooner, you can update their information BOTH in Insights on the Encounter Details page AND in your EHR.

For Patients Without an Appointment

Navigate to the Appointments page and click on Live Eligibility Check.

Fill in all required information, then click Check.

Note that it may take up to 30 seconds to see results.

In this example, we see an Inactive eligibility result. The next step would be to contact the patient for their latest insurance information and make updates accordingly in your EHR. Athelas will pull the new information from your EHR within 24 hours.

If a result returns Inconclusive, refer to the top of this guide for possible reasons.

❓Eligibility FAQs

• Does Insights track visit limits?

  Visit limits are not fully supported and not a standard offering of our eligibility check.
  We offer limited functionality with select payers. Please talk to our team to understand further.

  
  

• Does Insights track benefit maximums?

  There is a filter on the Denials page for Denial Reason: Benefit Maximum, so you can view all such current cases. This information is not currently surfaced on individual patient profiles.

  Currently, Insights does not create a notification when a patient nears their benefit maximum.

  
  

• Is there a notification for patients approaching their visit limit, or if there’s an issue?

  Yes, but it is currently only shown with the rest of the eligibility information. You’ll need to run an eligibility check to view those details.

  
  

• Once a claim is denied due to maxed benefits, is the patient automatically flagged so that the front desk can warn them?

  Not as of August 5, 2025.

  
  

Features Supported:

• Bulk submitting eligibility to Waystar for all appointments up to 4 days in the future

• Running medicare checks only in specified medicare windows

• UHC eligibility integration

• Ability to run a live eligibility check from Insights

• Ability to re-run eligibility for an appointment in appointment details

• Ability for operations to reroute insurance eligibility runs for through payer mappings

• Rerunning eligibility for appointments that have their insurance info change on the DOS

• Weekly job for select sites that runs eligibility for patients with recent encounters

• Auto re-running checks that fail at Waystar

Features In Development:

• Fully integrating availity into batch job

Features Not Supported:

• Live appointment integrations (cannot import appointments schedules <24 hours from current date). Can do it only for AIR EHR

• Prior Authorization requirements

• Site responsibility on specifying payers which are Out of Network

• Automated checks on payers not supported by Waystar or Availity

Integrations With:

• Waystar

• Availity

• UHC Payer Portal