Obtain patient benefit information and use it to leverage patient payments.
Features and Benefits
- Access InstaMed’s network of 800+ payers
- Batch or real-time processing
- Robust reporting
- Custom statuses to fit your workflow needs
- Printable and readable eligibility responses
- Reduce the possibility of denied claims
Eligibility inquiries and responses are electronic transactions defined under HIPAA and are assigned the transaction codes 270 and 271 respectively in the ANSI X12 standards. Eligibility transactions determine:
- If a carrier has an individual on file as a member
- The specific benefit information about that member
Eligibility can be checked when scheduling or at an appointment. Eligibility can also be used to troubleshoot claim processing issues. Using eligibility checks early and often can help ensure payment in a timely manner.
Use Cases
- Eligibility is verified at the following times:
- When the patient schedules an appointment in advance
- On the day of the appointment (both for scheduled appointments and “walk-ins”)
- After the patient has received services for issue resolution with claim processing
- Eligibility verification when the patient schedules an appointment in advance or after the patient has received services can be in batch or real-time mode.
- Eligibility verification on the day of the appointment can be in real-time mode when the patient registers at the service location or in batch mode if scheduled in advance.
Limitations
- Cannot determine whether a specific procedure is covered.
- Cannot provide a history of benefit use. For durable medical equipment (DME) suppliers, this is commonly called “same” or “similar” verification.
- Cannot be used to determine a Medicare patient’s identification number.
Supported Formats
- X12 4010 & X12 5010
Available for real-time and batch transactions - InstaMed Delimited Format (IDF)
Batch only pipe delimited custom format for when X12 is not supported
Integration Options
REST
InstaMed now offers REST. REST is a lightweight and easy-to-learn technology used in all areas of web development for integration of web services.
Explore our REST documentation for eligibility. If you need a Sandbox API Key, apply for one here.
Single Sign-On
Insert Eligibility Verification into your application using Single Sign-On. View the options using the wizard below. You can also learn more about integrating using Single Sign-On.
Posting
Batch eligibility results are available in InstaMed Online and via a batch file for posting to the originating system. InstaMed batch eligibility supports the following features:
- Automated Retry
Reduce the number of errors due to temporary unavailability of payer systems. When this service is enabled, all qualifying batch eligibility inquiries are resubmitted at a 30-minute interval for up to 24 hours. Qualifying transactions are those that receive responses with Request Validation (AAA03) values of “42 – Unable to Respond at Current Time” or “80 – No Response Received – Transaction Terminated.” The frequency of resubmission or maximum duration is configurable. The InstaMed platform returns a response only upon a successful inquiry or when the maximum duration has elapsed.
- Cascading Search
Cascading search increases the likelihood of a positive match in payer databases. When the service is enabled, all qualifying batch eligibility inquiries are re-submitted using all search options supported by the destination payer. Qualifying transactions are those that receive responses with Request Validation (AAA03) values of listed in Not Found Codes table. The InstaMed platform returns a response only when an inquiry is successful or when all available search options are exhausted.
Eligibility Not Found Codes Table
| Code | Description |
|---|---|
| 58 | Invalid/Missing Date of birth |
| 64 | Invalid/Missing Patient ID |
| 65 | Invalid/Missing Patient Name |
| 66 | Invalid/Missing Patient Gender Code |
| 67 | Patient Not Found |
| 68 | Duplicate Patient ID Number |
| 69 | Inconsistent with Patient's Age |
| 70 | Inconsistent with Patient's Gender |
| 71 | Patient Birth Date Does Not Match That for the Patient on the Database |
| 72 | Invalid/Missing Subscriber/Insured ID |
| 73 | Invalid/Missing Subscriber/Insured Name |
| 74 | Invalid/Missing Subscriber/Insured Gender Code |
| 75 | Subscriber/Insured Not Found |
| 76 | Duplicate Subscriber/Insured ID Number |
| 77 | Subscriber Found, Patient Not Found |
| 78 | Subscriber/Insured Not in Group/Plan Identified |
InstaMed Online
The simplest way to connect to InstaMed requires no integration at all. Leverage InstaMed Online and the InstaMed portals directly without embedding the functionality into another system.
A standalone user interface is the perfect solution for a kiosk or dedicated system. Using InstaMed Online requires the least amount of development work and means your users can start accessing their accounts right away.
- Take advantage of all InstaMed features and functions
- Extend future InstaMed features to your users as they are available
For more information on how to incorporate InstaMed standalone solutions, please contact us