Request eligibility and benefits report

An eligibility check asks the payer, in real time, whether this patient's coverage is active and what it pays for. It takes a few seconds, it happens from inside the claim, and it is the cheapest way to avoid a denial that was always going to happen.

Step 1: Open the Eligibility Check

Open any claim for the client from Money → Claims, then click the Eligibility pill in the claim header. The payer and provider details come from that claim's setup, so there is nothing to pick.

Step 2: Confirm the Patient's Details

Three fields drive the check, and the first two are pre-filled from the client record:

1. Member / policy number - the number on the patient's card. This has to match what the payer holds, character for character.
2. Date of birth.
3. Service type - what you are asking about. The default, Health benefit plan coverage, returns the broadest answer; narrower options include Physician visit - office, Mental health, Chiropractic, Dental care, Vision (optometry) and Urgent care.

Click Run check. Pabau contacts the payer through Claim.MD and returns the report in a few seconds.

Step 3: Read the Report

The report opens with a header carrying its report number, when it was run and the service type it was run for. Below that it is organised into three parts.

Policy details shows the two things you would otherwise phone the payer for: the plan on the left (payer, plan name, plan number, group name and the plan's start and end dates) and the insured on the right (name, member ID, date of birth, gender and address).

Coverage confirms whether the plan is live. An Active coverage chip means the payer says yes; alongside it you get the plan name, insurance type, when the payer last updated the record, and any notes attached to it.

Benefits is the cost-sharing detail, grouped by benefit type. Each row shows:

• Benefit - what it covers, such as a co-payment, co-insurance, deductible or out-of-pocket maximum.
• Network - In network, Out of network, or Not applicable.
• Value - the amount or percentage. Where the payer reports no limit, this shows as Unlimited.
• Period - the window the figure applies to, such as per visit or per calendar year.

Two sets of chips filter the benefit rows: All levels / Individual / Family, and All networks / In network / Out of network. Payers commonly return both an individual and a family deductible, so filtering to one is the quickest way to stop reading the wrong number.

Step 4: Go Back to an Earlier Report

Every check is kept. The Recent reports list on the eligibility panel shows previous checks for this patient with their date and service type - open one to read it again without spending another check. New check runs a fresh one when you need today's answer.

Step 5: Watch for Coverage That Needs Re-checking

Pabau also watches coverage from the client's side. On the client card's Insurance tab, a banner appears when the policy is worth re-checking:

• Coverage needs verification - the last check is old enough to be worth repeating before the next visit.
• The same banner appears when the most recent check came back showing inactive coverage.

Review policy on the banner opens the policy, where a fresh check can be run. Catching a lapsed plan here costs you a minute; catching it after adjudication costs a denial and a rebill.