Electronic Eligibility and Benefits
Electronic eligibility and benefit information allows you to electronically verify a subscriber's eligibility and benefits in real time (e.g. percentages, deductibles, maximums and limitations).
There are several options:
- Register with the vendor. If a clearinghouse, make sure Real Time Eligibility or "real time" services is enabled.
- If a clearinghouse, set the clearinghouse as your default dental clearinghouse. See Clearinghouse Setup.
If Trojan, enable the bridge. See Trojan. Then click Trojan on the Edit Insurance Plan window.
- Verify that each carrier's electronic ID is entered accurately in Open Dental (Edit Insurance Plan window or Edit Carrier window). To determine a carrier's electronic ID, check with the clearinghouse.
Retrieve Eligibility and Benefit Information from a Clearinghouse
Eligibility requests retrieve benefit information for subscribers only. If a request is sent for a patient who is not the subscriber, then only subscriber benefit information will be returned. See Patient vs. Subscriber below.
- On the Edit Insurance Plan window, click Request on the middle right.
- Double click on an item in the left column to see the individual benefit response.
Open Dental tries to interpret each raw benefit and to provide an equivalent Open Dental benefit object in the right column. Any of these can be imported, but it still takes a human to interpret the data. Most carriers still send very sparse data, frequently nothing more than single yes or no response on whether the patient is covered.
- Click Close to exit.
View Request History
On the Edit Insurance Plan window,
click History. All requests and responses are stored for future reference.
Patient vs. Subscriber: Eligibility requests are for subscribers only. If a request is sent for a patient who is not the subscriber, then only subscriber benefit information will be returned. Benefits for subscriber and patient are typically the same, but sometimes begin and end dates are different. This can lead to confusion if a request is outside a subscriber's coverage dates, but within the patient's coverage dates, or vice versa. In effect, the patient plan may appear 'active' even though 'inactive', or 'inactive' when 'active'. Workaround: To determine if a specific service will be covered for a patient, send a pre-authorization electronic claim.
The electronic eligibility format has a way to send a benefit request for the patient instead of the subscriber, but this would be a Feature Request. Importing the benefit response is difficult. When the patient is not the subscriber, importing the response would sometimes require creating a new plan so that the subscriber's plan is not altered.
In order to improve the automation in Open Dental, we are interested in seeing any situations where Open Dental could automatically interpret the benefits better. Especially long and complex responses. If the carrier returns a percentage breakdown by category, Open Dental should be able to easily import those percentages. If it can't we would like to see the response so we can improve the automation. Please contact technical support if you are willing to provide this information. The raw 271 response is accessible at the upper right of the e-benefit window.
Toggle between the Mark for import if... radio buttons to quickly mark all the in or out of network benefits for import. Only marked benefits will be imported when the Import button is clicked. Some benefit types that Open Dental does not yet import include:
Importing these types is considered a Feature Request. Our goal with this initial implementation is to get benefit information such as percentages, deductibles, maximums, limitations, and of course, eligibility.
Problem: Receive this error message: "There is a problem with your benefits request. Check with your clearinghouse to ensure they support Real Time Eligibility for this carrier and verify that the correct electronic ID is entered".
Solution: Your clearinghouse may not support Real Time Eligibility for the carrier or the electronic ID entered in Open Dental for the carrier may be inaccurate.
- Contact the clearinghouse to check on the carrier's Real Time Eligibility status.
- Verify that the carrier's electronic ID is entered accurately in Open Dental (Edit Insurance Plan window or Edit Carrier window). To determine a carrier's electronic ID, check with the clearinghouse.
Problem: Receive this error message: "...Error message received directly from Claim Connect: Deficient request - required data is missing."
Solution: Double check that all provider information in the Edit Provider window is entered correctly.