How to Add A Client Payer and Complete Eligibility Check

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Follow the steps below to verify a client’s insurance eligibility in the EHR, assign a fee for each service.

Typical Workflow

When a prospective client calls to ask about the cost of therapy or psychiatry, follow the steps below:

  1. Run a Pre-Check Eligibility
    • Use the Precheck Client fields to run an eligibility check for the caller’s insurance.
  2. Review and Interpret Eligibility
    • Review the eligibility results.
    • Identify key details such as deductible, copay, coinsurance, and network status.
  3. Provide Cost Information
    • Explain the estimated cost of services to the caller based on the eligibility results.
  4. If the Caller Decides to Proceed
    • Create a new client profile in the system.
    • Create the initial service record.
  5. Attach the Eligibility Record
    • Link the Precheck Eligibility Client to the newly created client profile to retain the eligibility information.

When a client signs up via the Client Portal (new EHR), follow the steps below:

  1. The client's info, service and payer will be prepopulated
  2. Click the Recheck Eligibility button

The Goal of the Client Payer List

On the EHR → Billing → Eligibility, the goal is ensure each client payer submission is completed, eligibility is checked, and client fees are entered. Take note of the warning icon in the Last Verified column. The warning icon will appear when the last verified is 30+ days old and/or is empty.

How to Add a Client Payer

  1. Navigate to the Eligibility Page
    • Go to EHR → Billing → Eligibility.
  2. Add a Client Payer
    • Click + Add Client Payer.
  3. Select the Client
    • Use the Precheck fields or select an existing client from the dropdown list.
    • Precheck Client First Name, Precheck Client Last Name, Precheck Client DOB
  4. Enter Payer Information
    • Select the payer.
    • Enter the client’s Member ID.
    • Select whether that payer is Primary or Secondary or falls in another position.
      • Add another Client Payer for each payer of the client (primary, secondary, etc.). Check eligibility for each payer independently.
  5. Complete Additional Fields
    • Enter any other known information before saving.

Run Eligibility Check

  1. Add the following details under the Client section. The Precheck Client details allows you to enter client information without creating a client profile first, later you can associate the Precheck Client to an actual client.
    1. Precheck Client First Name
    2. Precheck Client Last Name
    3. Precheck Client DOB
    4. Primary Payer
    5. Primary Payer Member ID
  2. Click the Add & Check Eligibility button. The results will appear in the Client Billing table.

Review the Benefits Status

Check the Eligibility Status column in the results table.

  • Active Coverage – The eligibility verification was successful and the client's plan is active.
  • Failed – The verification did not process successfully. Either the eligiblity check was missing info or the wrong info was sent.

Resolve Failed Checks

If the status shows Failed:

  1. Click the eligibility to view the error message in the Primary Eligibility Results section.
  2. Review the information submitted.
  3. Correct any missing or incorrect details.
  4. Resubmit the eligibility check.

Complete the Eligibility Results Section

After reviewing the client’s benefits, complete the Eligibility Results section.

  1. Select the plan type (Copay or Coinsurance).
  2. Enter the Deductible amounts: Contract and Remaining.
  3. Enter the Out-of-Pocket (OOP) amounts: Contract and Remaining.
  4. Check Deductible Applies (primarily used for coinsurance plans).
  5. Enter the Copay amount.
  6. Enter the Coinsurance amount.

Note: Each of these fields must be complete in order to Calculate Fee and produce a GFE.

Calculate Client’s Fee and Create GFE

Follow the steps below when creating a GFE. If the client has multiple payers (primary and secondary), create the GFE using the lowest client fees, usually the secondary payer.

  1. Click on the desired Client Payer.
  2. In the right-hand column, click Calculate Fees.
    • This calculates the payer’s reimbursement rates using the primary payer rates and the data entered in the Eligibility Results section.
  3. Adjust the amounts if needed.
  4. Click Create GFE.
    • A PDF will be generated.
  5. Upload the GFE PDF to the client’s file in TN.