Eligibility Self-Service Setup Guide

Athelas Insights verifies patient eligibility prior to appointments and calculates estimated patient responsibility (copays, deductibles, coinsurance, and self-pay). This guide explains how eligibility data flows into Insights, how to read the results, and how to configure the rules that power your Patient Responsibility (PR) recommendations.

• Automated Checks — Automated checks run 7 days before the scheduled appointment for insurances supported through the Waystar, Availity, and UHC clearinghouses.
• EHR Data Flow (AIR-Billing Only) — Insights uses a one-way extraction to pull appointments, patient demographics, and insurance data from your EHR.

• Live Checks — For patients without a scheduled appointment, use the Live Eligibility Check button to verify coverage in real time.

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Reading the eligibility status

Each insurance shown on an appointment displays a badge indicating the result of its eligibility check:

• The patient has active insurance coverage with this payer.
• The patient does NOT have active insurance coverage with this payer.
• We were unable to get an active or inactive response from the payer.
• We were unable to retrieve an active or inactive response from the payer. This is called an Inconclusive result and is usually caused by incorrect patient information, such as the name, date of birth, or member ID.

Hover over the icon to see what needs to be corrected before running the eligibility check again. The table below lists the most common inconclusive responses and next steps.

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Types of eligibility rules

To generate an accurate Patient Responsibility suggestion, Insights first parses a patient’s insurance benefits, such as copays, deductibles, and coinsurance. This information comes from Waystar, Availity, and UHC. Patients often have multiple benefits, but not all are relevant to the PR calculation. After parsing the data, Insights applies rules to identify and use only the benefits needed. Before configuring eligibility rules, it’s important to understand the three rule types used by the eligibility engine:

• Appointment Rules
• Eligibility Parser Rules
• Suggested PR Rules

Each rule type serves a different purpose. The following sections explain how each one works.

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Appointment Rules

Appointment Rules map appointment types to the correct Service Type used in the eligibility inquiry. A Service Type identifies the healthcare service being provided and determines which benefits the payer returns. Common service types include Physical Therapy (PT), Physical Medicine (AE), and Professional Office Visit (98). For most sites, all appointment types are mapped to the site’s specialty. For example, a Physical Therapy practice maps all appointment types, such as Initial Evaluation and Follow-up, to PT. For more complex practices, appointment types are mapped individually based on the services provided. Appointment Rules can also apply payer-specific exceptions, such as using a different Service Type or Rendering/Group NPI for certain payers.

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Accessing Appointment Rules

Step 1: From the Appointments page, open the three-dot menu and select PR Settings. Step 2: On the Patient Responsibility Settings page, select the tab for the type of eligibility rule you need to configure. We will first set up our Appointment Rules. Step 3: Click Add Rule and this will pop up: Step 4: Creating an Appointment Rule

• Name the rule — The rule name is for your reference only and can be named anything.
• Set the priority — Assign a priority value, such as 10, to determine the rule order.
• Set the Service Type Code — Select Set Service Type Codes and choose your facility’s appropriate Service Type.
• Add NPI details — Click Add Action and enter the Primary and Secondary NPIs for your site. We recommend setting the Group NPI as the Primary NPI and a provider’s NPI as the Secondary NPI.
• Select appointment types — Choose which appointment types the rule should apply to. If the rule applies to all appointments, add a fail-safe condition and save the rule.

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Eligibility Parser Rules

Eligibility Parser Rules control how benefits returned by Waystar are prioritized when multiple valid benefits are available. Refer to the images above to access PR Settings and Eligibility Parser Rules. The most common use case is ranking one benefit higher than another. For example, if a site wants to recommend the Specialist copay, you can assign additional ranking points to benefits with a payer note containing “Specialist.” If both Specialist and Non-Specialist copays are returned, the system will prefer the Specialist copay. In most cases, ranking is preferred over excluding benefits. If the Specialist copay is unavailable, the system can still fall back to the Non-Specialist copay instead of returning no recommendation. Use Parser Rules only when the eligibility response contains multiple valid benefits and the wrong one is consistently selected. First confirm that the appointment Service Type and payer mapping are configured correctly — a number of rules have likely already been created for your benefit. Common actions to experiment with: Add Ranking Points (usually to parse a specific type of co-pay), Display Benefit on Insights, Exclude, Include. Common variables to experiment with: Appointment Type, Eligibility or Benefit Information Code, General Plan Coverage Description, Payer Note. The example below recommends the primary copay for all BCBS member IDs that start with “R” — first the parser rule’s conditions, then its actions:

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Suggested PR Rules

Once eligibility parser rules have been developed, it’s time to set the PR rules. You can use PR rules to set payer-specific PR recommendations, prioritize copays over others, and set coinsurance as a percentage of the fixed amount which you can set manually. Refer to the images above to access PR Settings and Suggested PR Rules.

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Creating Suggested PR Rules

Once you click Add rule, this will pop up:

• Rule details — Use a descriptive label for the Name (e.g., “UHC Deductible Rule”), assign a priority where higher numbers win when multiple rules match, and use the End date toggle for temporary or inactive rules.
• Rule logic — Actions define what the rule does (set an amount, prioritize a benefit, set service type, set NPI, or notify), while Conditions determine when the rule applies (payer, appointment type, facility, age, provider, or benefit values). You can choose between All (requires every condition) or Any (requires one condition).

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Configure Patient Responsibility Rules

Create four core PR rules. Their relative priority determines which recommendation wins when more than one rule matches the appointment. Rule type: Suggested PR Rule.

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Overriding a Suggested Recommendation

If the suggested patient responsibility is not correct once your rules are configured, you can override the recommended amount for an individual patient. Step 1: On the Appointments page, click the gray area of the appointment row. Do not click the patient name or the insurance name, as those open different views. Step 2: In the expanded appointment view, select the shield icon in the upper right. Step 3: In the Charge Override window, enter the amount you want to apply, leave the remaining fields as they are, and select Submit. From that point forward, the recommendation for that patient and appointment type will be the amount you entered.

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Rules already configured for your site

Some rules are already set up for your site by default, so you do not need to create them. Review them so you understand how they interact with the rules you configure yourself, since their priorities determine which recommendation wins when more than one rule matches an appointment. Prioritize Copay, the Out-of-Pocket rule, and the Secondary Insurance rule are Suggested PR Rules, and the PT mapping rule is an Appointment Rule. All four are already configured for your site.

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Prioritize Copay

• Actions: Prioritize Copay From Benefits; set deductible and coinsurance amounts to $0.
• Conditions: Copay greater than $0. An appointment-type condition applies only when copay workflows differ by specialty.
• Priority: Set above deductible and coinsurance, but below the OOP rule.

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Out-of-Pocket rule

Rule type: Suggested PR Rule.

• Actions: Set Copay Amount and Deductible Amount to $0, then add a notification that the patient has met out-of-pocket.
• Conditions: Individual or family out-of-pocket remaining equals $0.
• Priority: Highest of the four PR rules so it suppresses any collection recommendation.
• Result: When OOP remaining is $0, the appointment should show no suggested charge and a notification that the patient has met out-of-pocket.

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Secondary Insurance rule

Rule type: Suggested PR Rule.

• Actions: Set Copay Amount, Coinsurance Amount, and Deductible Amount to $0.
• Conditions: Secondary Payer shares no elements with SELF-PAY (NO INSURANCE); Secondary Member Id is not empty.
• Priority: The same as the Out-of-Pocket rule, so it outranks Prioritize Copay and suppresses the copay recommendation.
• Why: When a patient has both primary and secondary insurance, the patient responsibility passed by the primary payer is usually covered by the secondary payer, so no amount is recommended for upfront collection.

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PT mapping rule

Rule type: Appointment Rule.

• Actions: Set Service Type Codes to PT – Physical Therapy.
• Conditions: Set to “Any,” with Appointment Type Is Empty and Appointment Type Non Empty. Together these act as a fail-safe so the rule applies to every appointment type.
• Priority: 50.
• Why: The practice is a Physical Therapy site, so eligibility checks prioritize Physical Therapy benefits, which are the most relevant benefits returned for these appointments.

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Adding more PR rules to improve upfront collection

Beyond the rules already configured for your site, you can add more Suggested PR Rules to improve how much patient responsibility is collected upfront. Refer to the images earlier in this guide to access PR Settings and Suggested PR Rules.

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Deductible rule

• Action: Select Set Deductible Amount and enter the approved upfront amount in cents.
• Conditions: Scope by payer and/or appointment type. Use an “Any” group when either individual or family remaining deductible can trigger the rule.
• Example: For UHC, if either remaining deductible is greater than $55, recommend $55 (5,500 cents).

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Coinsurance rule

• Actions: Set Deductible Amount to $0 and Set Fixed Fee to the approved base fee.
• Conditions: Payer matches; coinsurance percentage is greater than $0; at least one remaining/calendar-year deductible value equals $0.
• Why priority 30: It should override the deductible rule when the deductible is met.

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Out-of-Network (OON) insurances

For insurance plans where you want to retrieve Out-of-Network benefits instead of In-Network benefits, you need to map those plans accordingly. From PR Settings, click Out of Network Insurances. Select the insurance plans that are out of network (OON) for you. If an insurance plan is out of network only for specific facilities, select those facilities accordingly. To add multiple out-of-network insurance mappings, click Add Mapping for each additional entry. When you have finished, click Save.

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Configure custom payment types

Use custom line items for charges outside copay, coinsurance, and deductible. After configuration, the line items are available in the appointment payment collection workflow.

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Choose the correct type

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Create a custom payment type

1. Open PR Settings and scroll to Custom Payment Types.
2. Select the plus icon in the upper-right corner.
3. Enter the Name, choose Type, set Status, and enter the Default Charge Amount in dollars.
4. Leave the default amount blank when staff should enter the amount at collection time.
5. Select Create.

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Use custom line items during collection

Add the line item to an appointment:

1. Open the appointment payment collection flow.
2. Open the Type dropdown or search for the line item by name.
3. Select the line item. Its configured default amount appears automatically.
4. Adjust the amount or quantity when the workflow permits multiple units.
5. Choose the payment method and complete collection.

You can also find the line item by typing its name directly into the Type field to search for it. Note: When the same line item has multiple units, update the quantity before confirming the payment.

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Edit, disable, or replace a custom line item

To edit an existing item:

1. Return to PR Settings → Custom Payment Types.
2. Search for the line item and select the pencil icon.

3. Update the Name, Default Charge Amount, or Status.
4. Select Disabled to hide the item from the payment collection menu.
5. Select Update to save the changes.

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Confirm the intended accounting behavior

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FAQ

Can I override a suggested Patient Responsibility amount for a specific patient?

Yes. Open the appointment’s expanded view, select the shield icon, and use Charge Override to set a specific copay, deductible, coinsurance, fixed fee, or self-pay amount. Enter the amount in cents (for example, 1000 for $10). From that point forward, the override applies to that patient and appointment type going forward.

Why do all my Suggested PR Rule and Charge Override amounts need to be in cents?

The rules engine and the Charge Override window both store amounts in cents to avoid rounding errors. Entering a dollar amount instead (for example, 10 instead of 1000) will apply a recommendation for $0.10, not $10.

What happens when a patient has both primary and secondary insurance?

The Secondary Insurance rule, already configured for your site, sets Copay, Coinsurance, and Deductible amounts to $0 whenever a secondary payer and secondary member ID are on file. This is because the patient responsibility passed by the primary payer is usually covered by the secondary payer, so no amount is recommended for upfront collection.

What's the difference between Standard, Self Pay, and Add Credits custom payment types?

Standard records a separate charge that stays independent of claim reconciliation. Self Pay automatically applies to all encounters (insured or not) and reconciles against the encounter’s final patient responsibility. Add Credits adds patient account credit instead of a charge. The type cannot be changed after creation — disable the item and create a new one with the correct type instead.

My Suggested PR Rule isn't applying — what should I check?

Confirm the rule’s priority relative to the other rules that could match the same appointment; the highest-priority matching rule wins. As a starting point, the Out-of-Pocket rule should outrank Prioritize Copay, which should outrank Coinsurance and Deductible. Also confirm the appointment’s Service Type and payer mapping under Appointment Rules are correct, since a mismatch there can prevent the right benefits from being evaluated in the first place.

How do I run or re-run an eligibility check itself, rather than configure the rules behind it?

See How to Run an Eligibility Check for the day-to-day workflow, and the Patient Eligibility Report to track eligibility results across all patients.