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At a Glance

Eligibility is the determination of a patient’s qualification for healthcare services based on factors such as insurance coverage, benefits, and provider network. Eligibility checks return one of several results — most commonly Active, Inactive, or Inconclusive. You may also see Not Covered, Pending, None, Self Pay, or Site Responsibility. Checks are service-type based and provide tailored recommendations for copay, deductible, and coinsurance. You can map appointments to relevant service types (for example, office visits, physical therapy, or mental health) under PR Settings → Appointment Rules.

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Inconclusive Eligibility Checks: Possible Causes

  • Not all payers are supported. Our manual team looks up benefits where we can. If you keep seeing inconclusive results, please flag it to us.
  • Missing or malformed data. We occasionally receive data in unexpected structures. Flagging issues helps us find and fix them.
  • Rules may be misfiring or missing. An overly inclusive rule can trigger when it shouldn’t. Your account management team can help assess your practice’s rules.
  • Bad mapping. Mis-mappings can produce inconclusive results. If a particular insurance repeatedly returns inconclusive, contact your account manager.

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Here’s How to Do It

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Re-run Eligibility for an Existing Appointment

Open the appointment’s detail page and go to Eligibility Central. Here you can review the current result and click Re-run Eligibility to run a fresh check, or See More Details to view the full benefits response. You can also click an insurance’s eligibility badge directly in the Insurances column of the appointment list to open the response and re-run.
Eligibility can only be run for appointments up to 14 days in the future.
If a check returns Inactive, contact the patient and update their information in your EHR — Insights will pick up the change automatically. If you need it sooner, update the information in your EHR and on the Encounter Details page.

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Run a Check for a Patient Without an Appointment

From the Appointments page, click Live Eligibility Check. A Run Eligibility Check drawer opens. Fill in the patient information, Insurance Name, Provider, and Date of Service. Optionally, you can Override Service Type or choose a specific Source (clearinghouse) to check against. Then click Check. Results open in an Eligibility Response drawer (this can take up to about 30 seconds). If the result is Inactive, contact the patient for their latest insurance information and update your EHR accordingly. If it’s Inconclusive, refer to the causes at the top of this guide.

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FAQ

Insights checks eligibility through multiple sources, including Availity, Waystar, UHC, CHC, BCBS, and Infinx. The available sources depend on the payer.
Visit limits are supported for select payers as part of the eligibility response, not as a standalone offering. Talk to our team to understand coverage for your payers.
Yes. When running a live eligibility check, use Override Service Type to run the check against a specific service type instead of the default.
Eligibility can only be run for appointments up to 14 days ahead. For appointments further out, run the check closer to the date of service.