Run an Eligibility Check for Your Care Request

Verify members’ benefits coverage and check which care request services require an authorization.

Note You aren’t required to run an eligibility check for a concurrent review that's linked to an existing request.

Available in: Lightning Experience

Available in: Enterprise and Unlimited Editions with Health Cloud

User Permissions Needed
To run an eligibility check:	Health Cloud Utilization Management, OmniStudio User, and RuleEngine Runtime permission sets

From App Launcher, go to the Utilization Management for Payers app.
Select an authorization request type.
In the Check Eligibility window, search for the member by name or ID.
The member name and birthdate are auto-populated.
For concurrent review that’s not linked to an existing request, select the review type as Inpatient or Outpatient.
Select the service date for the authorization request, and click Show Member Plans.
Select an insurance plan your member is enrolled in.
Check if the member’s required service needs authorization.
1. Click Search Codes.
2. Enter and select a code set name or code. The available codes and code set names are set up by your admin.
3. Save your changes.
4. Back on the Check Eligibility screen, select Search Codes to add more codes.
  
  Note You can add a total of 12 codes.
5. Click Check.
  You can see which of the searched codes require an authorization. This check is automatically run based on rules configured by your admin. Contact your admin for more information.
Click Next to go to the next screen in the Authorization process.

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