Coverage Detection

How Coverage Detection Works

When you initiate a Coverage Detection request, the system:

1. Submits a special eligibility request to Waystar via the Eligibility API
2. Searches Waystar's internal databases containing millions of patient claims and eligibility records
3. Queries major payers in real-time including:
   • Aetna
   • Cigna
   • UnitedHealthcare (UHC)
   • Medicare/Medicaid (based on patient's state and age)
4. Returns discovered coverage with patient match scores to help you determine accuracy
5. Filters results through Waystar's intelligence engine to remove non-viable coverage options

Response Time: Coverage Detection typically returns results within 10-30 seconds. In rare cases where payers experience connectivity issues, it may take up to 1 minute.

When to Use Coverage Detection

Use Coverage Detection when:

• An eligibility check returns inactive coverage
• No insurance is on file for the patient
• You need to discover insurance before the patient can provide information
• Standard eligibility checks are unable to verify coverage

Important: Because Coverage Detection incurs a billable charge from Waystar, use it selectively rather than automatically for all patients with inactive insurance.

How to Use Coverage Detection

Coverage Detection is initiated manually, giving you full control over when to incur charges.

Steps:

1. Navigate to the Insurance Eligibility screen for the patient
2. Verify patient demographic information is complete (see Best Practices below)
3. Click the "Coverage Detection" button
4. Wait for results (10-30 seconds, up to 1 minute maximum)
5. Review discovered coverage results by selecting one from the results grid

Understanding Coverage Detection Results

No Coverage Found

If Waystar cannot discover any active insurance, the system displays a "No Coverage Found" message with varied messaging depending on the issue (example below):

This indicates that Waystar's databases and real-time payer queries did not find any active coverage for the patient (or could not identify the patient). You may need to contact the patient directly for insurance information.

Coverage Found

When coverage is discovered, the system displays:

• All discovered payer coverages
• Patient match scores for each discovered insurance
• Coverage details returned from the payer

Patient Match Scores: Waystar assigns a confidence score to each discovered coverage indicating how certain they are that the insurance belongs to your patient (rather than someone else with a similar name/DOB). Strong match scores indicate greater confidence in the match.

Multiple Coverages: Coverage Detection may return multiple insurance options. The system displays one coverage per result, allowing you to review all options before selecting. Select an insurance to load the eligibility results for that insurance - it will be highlighted in blue as shown above while selected.

Adding Discovered Coverage

After reviewing discovered coverage:

1. Review the patient match score to ensure confidence in the match
2. Select the appropriate coverage from the results
3. Add or update the patient's insurance record with the discovered coverage details

Best Practices for Coverage Detection

Include Complete Patient Demographics when able:

• Patient address - Helps Waystar assign accurate patient match scores
• Social Security Number (SSN) - Optimizes performance for payers that accept SSN as Member ID (Medicare, Tricare, BCBS)

The more complete the patient demographic information, the more accurate the Coverage Detection results will be.

Verify Before Billing:

• Review patient match scores - lower scores may require additional verification
• Contact the patient to confirm insurance if match scores are low or results seem uncertain

Use Selectively:

• Coverage Detection incurs billable charges from Waystar
• Use when you genuinely need to discover insurance, not routinely for all inactive results
• Consider the cost/benefit for each Coverage Detection request

Billing and Charges

Important: Coverage Detection is a billable service through Waystar. Your organization is charged for each Coverage Detection transaction .

• Standard eligibility checks using specific payer IDs do NOT incur Coverage Detection charges (only standard Eligibility charges, which tend to be significantly lower)
• Charges are determined by your Waystar contract

Contact your Waystar representative for specific pricing information.

When to Contact AIM Support

Contact AIM Support for assistance with:

• Coverage Detection feature not appearing or not working
• Questions about how to interpret patient match scores
• Issues with adding discovered coverage to patient records
• Errors or unexpected behavior during Coverage Detection requests
• Questions about Coverage Detection setup or configuration

For questions about Coverage Detection charges or pricing, contact your Waystar representative directly.

Related Features

Insurance Eligibility: Standard eligibility verification for known insurance coverage. See the Insurance Eligibility help article for details.

Medicaid Eligibility Management: Automates Medicaid eligibility verification and tracking. See the Medicaid Eligibility Management help article for details.

Deductible Management: Tracks patient deductibles to maximize reimbursement efforts. See the Deductible Management help article for details.