Insurance Verification / Eligibility Check

Clearinghouse Connection

Your organization uses one of two clearinghouse options for electronic claims submission or integrated eligibility functions:

• Trizetto 
• Waystar

The clearinghouse your organization uses was selected during implementation based on service costs and features. By default, eligibility uses the same credentials as your electronic claims transmission. Credential requirements may vary by clearinghouse. Multi-agency Waystar customers experiencing eligibility issues should contact AIM Support to verify credentials are configured correctly for each agency.

Accessing the Insurance Verification Screen

To open the Insurance Verification screen, navigate to the Payers Tab of a bill and click the "Insurance Verification" button in the top right. If patient information and/or insurance payers are already available on the bill, most information automatically populates.

At the top of the screen, a Mode dropdown provides two options: Insurance Verification and Coverage Detection. Insurance Verification is selected by default. Switching between modes does not trigger any chargeable API calls or clear existing results from either side.

• Insurance Verification — Used to check eligibility for a specific payer. Displays the Payer, MBI/Policy Number, Payer Information fields, and the Check Eligibility button.
• Coverage Detection — Used to search for active insurance coverage without specifying a payer. Displays the Coverage Detection button and Active Coverage Results Grid. This mode is only available when Coverage Detection is enabled for your agency.

Required Fields for Eligibility Check

The following fields are required when running an eligibility check in Insurance Verification mode:

1. Bill Number (auto-populated)
2. NPI Number (National Provider Identifier - pulled from setup)
3. Commercial Electronic ID (Com Elec ID) (identifies the payer - enter Com Elec IDs in Commercial Payers Setup to pull them automatically when a Payer is selected, or add common Com Elec IDs in Quick Picks Setup for non-commercial payer types like Medicaid and Medicare)
4. Payer (selected insurance company)
5. Insured First and Last Name
6. Patient and Insured Address (city, state, zip are pulled from the Primary Insured Member details on the Information Tab of this bill - editing/removing the addresses here will only remove them from the eligibility request, not the Information Tab)
   1. These fields will be hidden by default. Users can view them by clicking on the Insured/Patient Addresses section. 
   2. When the section is expanded, users are able to use the EXCLUDE ADDRESSES FROM REQUEST button to remove the address details from the eligibility request. This is a requirement for some payers. Re-selecting a payer will add the addresses back to the request.
      
7. MBI/Policy Number (Insured ID/Subscriber ID)

Note: Required information may vary by payer. Some payers require an additional "Other Eligibility ID" for eligibility inquiries.

Field Details

Bill Information

Bill Number: Automatically populated and not editable.

NPI Number: Unique identifier for each company, pulled from setup. This field should never be blank. If it appears blank on a Medicare or Medicaid claim with multiple NPI numbers, use the quick pick selection to choose the desired number. 

Commercial Electronic ID: Identifies the payer being used for the eligibility check. Commercial Electronic IDs should be entered for each commercial payer in Commercial Payer Setup for full use of the eligibility feature.

Other Eligibility ID: A secondary ID required by some payers when sending eligibility inquiries.

Service Type: Defaults to "Health Benefits Plan Coverage." Use the dropdown to change this selection if needed.

Payer Selection

The payer list can be viewed two ways:

• Current Bill: Shows only the payers on the current bill
• Available Payers: Shows all installed payer types (Medicare, Medicaid, etc) and all commercial payers from Commercial Payers Setup

Insured Information

Insured information pulls from the Billing Information Tab > Insured Information Section. This provides information about the primary policy holder (self, spouse, child, etc.). For the best, streamlined experience, complete this section before conducting an eligibility request.

In Coverage Detection mode, these fields are labeled as "Patient" rather than "Insured" (e.g., Patient First Name, Patient Last Name) since a specific insured relationship is not required for a coverage search.

How to Check Eligibility

1. Ensure all required fields are populated (see Required Fields section above)
2. Click the Check Eligibility button
3. Review the results displayed under Eligibility Results

After Checking Eligibility

Last Successful Verification Field: Updates to current date and time immediately (no screen refresh required)

By Field: Updates to show current user for the date of service verified for

Understanding Eligibility Results

Successful Verification

When eligibility verification is successful:

• "Payer Verification Was Successful" message appears under Eligibility Results
• Insurance information displays at bottom of screen
• Click section titles (Active Coverage, Co-Insurance, Deductible, etc.) to view details

Insurance Verification and Coverage Detection results are retained independently. Switching between modes or closing and reopening the screen does not clear results from either side. Results are only replaced when a new request is run in that mode.

Visual Alerts for Denial Prevention

The system includes visual alerts and indicators to help prevent CO109 denials by highlighting commonly missed coverage details:

Medicare Part A Only Detection: When a Medicare eligibility check shows only Part A coverage, the system will NOT display "Active" status. Part A does not cover ambulance services, so this prevents billing errors.

Railroad Medicare Indicator: When eligibility results show Railroad Medicare coverage (instead of standard Medicare), the system displays a visual alert in the Active Coverage section. Railroad Medicare will most likely need to be billed instead of standard Medicare when this displays.

Services Capitated Section Alert: When the Active - Services Capitated section contains data, a visual indicator appears. This section may show managed care or replacement plans that should be billed instead of straight Medicaid.

Contact Following Entity Section Alert: When the "Contact Following Entity for Eligibility or Benefit Information" section shows a primary payer under related benefits, a visual alert appears to highlight the replacement plan.

Pharmacy Coverage Filtering: If the Other or Additional Payer section contains only Pharmacy coverage, the system automatically hides this section to reduce clutter and focus attention on relevant ambulance coverage.

Important: These visual alerts help identify replacement plans and coverage details that are commonly missed during billing. Always review all eligibility result sections carefully, even when verification is successful.

Primary Payer Differences

If verification is successful but finds a different primary payer:

• "Primary Payer is Different" message appears under Eligibility Results
• Click the exclamation icon (!) to view Other or Additional Payer Insurance Details and see the correct payer

Key Sections to Review:

• Active Coverage
• Services Capitated (indicates managed care/replacement plans)
• Other or Additional Payer (may show replacement plans)
• Contact Following Entity for Eligibility or Benefit Information

Missing replacement plan details is a common cause of claim denials. Pay close attention to visual alerts and all result sections.

Unsuccessful Verifications

If verification fails:

• Error message appears under Eligibility Results
• Review the error message
• Make needed updates to patient/insurance information
• Re-verify eligibility

Common Error: "The clearinghouse is not responding to this eligibility inquiry" - This indicates the clearinghouse cannot retrieve eligibility from the third party. Contact AIM Support if this error persists.

Manual Verification

If a commercial payer cannot be verified through the eligibility system:

1. Complete manual verification through your clearinghouse's third-party website
2. Once verification is complete, log it in AIM by clicking the Verify Insurance button in the Payer Details section of View Payers

Enforcing Eligibility Checks

Eligibility checks can be enforced to ensure billers always check eligibility for specific payers or within set timeframes. Multiple setup options control this behavior:

Per-Payer Enforcement:

• Navigate to General Setup > Commercial Payers
• Enable "Enforce Last Verified At Date" for specific payers
• Must also enable "Mandatory" for Commercial Payers in Billing > Field Configuration

Global Commercial Enforcement:

• Navigate to Billing > Field Configuration Setup > Bill Payers page
• Enable "Last Verified At Date" for Commercial payers
• If "Mandatory" is enabled, an eligibility check must be attempted before saving a bill (if not yet printed/transmitted)

Timeframe Configuration:

• Navigate to Billing > Configuration Settings
• Set "Last Verified At Number of Days" to indicate days allowed since last eligibility check

Note: These settings are typically configured during implementation. Contact AIM Support if enforcement settings need adjustment.

Related Features

Coverage Detection (Waystar only): Coverage Detection is now available directly on the Insurance Verification screen via the Mode dropdown. When eligibility returns inactive coverage, Coverage Detection can search for active insurance coverage without specifying a payer. This feature must be enabled for your agency — contact AIM Support 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.

When to Contact AIM Support

Contact AIM Support for assistance with:

• Eligibility setup or configuration issues
• Persistent clearinghouse connectivity errors
• Unusual or unclear error messages

Most eligibility errors are situational and require Support review to resolve.