Eligibility

Insurance Policy/Eligibility

An insurance Policy defines the static elements of insurance coverage. It defines who is covered, how coverage applies to different types of care, annual deductibles, region (state), etc.

Eligibility tracks the dynamic elements of a Policy. The patient’s current active/inactive status, the start and ending dates of coverage, the patient’s progress towards meeting deductibles and limits.

Provider Eligibility

To deliver care, a Provider must be individually enrolled with the Payer that supplied the Policy to the Patient and licensed in the region (state) where the patient is located.

Service Eligibility

Consider a Service to be an instance of delivering care. This translates to an individual appointment or telehealth visit. The type of Service being rendered, is used to determine whether an Insurance Policy is able to cover it.