Eligibility Checks

Many patients are unaware of their insurance information, whether it be for a Medicare Part D plan or a Commercial Insurance. This can make it difficult for a pharmacy to bill the proper third parties for a patient's prescriptions. But by doing an Eligibility Verification for a patient, you can obtain all of their insurance information and automatically add it into your system. Here are the instructions for how you can do this.

1. Go to the main screen of the pharmacy program. If you look towards the top (above the options for New Rx, Edit, Refill, Display/Reprint Label and Price Check), you will see a bunch of tabs. The fifth tab says Eligibility Verification. Click on that tab.

2. If the patient is already in the system, search for the patient and select them. When you select the patient, all of their information will automatically be displayed in the boxes. If the patient is not in your system, type in their name in Last Name, First Name format, and enter their Zip Code, Date of Birth and their Gender.

3. After entering the patient's information, you must select a plan. From the drop-down box, choose the insurance plan E1_MEDD_RH to check for Medicare Part D plans through Relay Health or E1_COMM_RH to check for Commercial insurances through Relay Health. If you are currently using Emdeon for your switch vendor, select the plan E1_EMDEON for all queries. These are the plans you need to use for eligibility checks and they have been automatically added into your system.

4. For the Card ID you should enter ONE of the following:

   1. Last 4 digits of the patient’s Social Security Number.

   2. The patient's entire Social Security Number.

   3. The patient’s Card ID from their Part A or Part B card.

5. After entering this information your screen should look similar to the picture below. The essential fields you need to fill in are the Patient Name (in LastName,FirstName format), Zip Code, DOB, Gender, the Plan (should be E1_MEDD_RH for Medicare Part D plans or E1_COMM_RH for Commercial insurances, E1_EMDEON for Emdeon queries), and the Card ID.

6. Once you have filled in all the necessary information, click the Transmit button. Once you get the response, your screen will look something like the picture below. This patient has 4 plans, and all of their information is displayed on the screen.

7. Once the information is displayed on the screen, you will see a button that says Update Patient Information. Once you click on that button, the following things will happen.

   1. If any of the insurance plans shown are not already in your system (determined by BIN# and Proc Control#), the program will bring up a screen that will allow you to add those plans.

   2. The program will take you to the Patient File.

      1. If this patient is not in your system, it will prompt you to add the patient. The patient’s Name, Zip Code, DOB and Gender will already be displayed. Also, the Insurance information will be filled out according to the information from the Eligibility check. Fill in the rest of the information and click Save the patient. MAKE SURE YOU SAVE THE PATIENT; otherwise the information will not get updated into your system.

      2. If the patient is already in the system, it will take you to the Insurance Plans tab of the Patient File and will display all the Insurance information returned from the Eligibility check. If necessary, add any extra information that was not displayed automatically and Save the information. MAKE SURE YOU SAVE THE INFORMATION; otherwise the information will not get updated into your system.

8. Now all the information has been updated into your system. Click on the To Rx Processing button and you can now go ahead and process prescriptions for this patient.