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Documentation Index

Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt

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Module: Practice Management (PM)
Feature: Insurance & Eligibility Verification
Version: 1.0.0 | 2026-02-18

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Prerequisites

You need the following permissions to use these features:
PermissionWhat it allows
pm.insurance.viewView patient insurance policies and eligibility history
pm.insurance.manageAdd, edit, terminate, or remove insurance policies
pm.eligibility.runRecord eligibility check results
pm.payers.viewView the payer directory
pm.payers.manageAdd, edit, or deactivate payers
Contact your administrator if you are missing any of these permissions.

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Adding Payers (Payer Directory)

Before adding insurance policies for patients, your organization must have payers configured.
  1. Navigate to Practice Management → Payer Management (/pm/payers).
  2. Click Add Payer.
  3. Fill in the required fields:
    • Payer Name (required) — e.g., “AHCCCS / DES”
    • Payer Type — commercial, Medicaid, Medicare, TRICARE, workers’ comp, or other
    • Electronic Payer ID — used for 270/271 eligibility transactions (PM-15)
    • Clearinghouse Payer ID — used for claims routing (PM-15)
  4. Click Save.

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Deactivating a Payer

Deactivated payers are hidden from insurance policy dropdowns but remain in historical records.
  1. Find the payer in the list.
  2. Click Deactivate (or Activate to re-enable).

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Removing a Payer

Only Org Admins can permanently soft-delete a payer. Click the trash icon and confirm.

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Managing Patient Insurance Policies

Insurance policies are managed from the patient’s detail page.
  1. Navigate to Practice Management → Patients and open a patient record.
  2. Click the Insurance tab.

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Adding a Policy

  1. Click Add Policy.
  2. Complete the form:
    • Payer — select from active payers in your directory
    • Policy Number (required)
    • Group Number (optional)
    • Coverage Type — commercial, Medicaid, Medicare, TRICARE, self-pay, sliding scale, or other
    • Priority Order — 1 = primary, 2 = secondary, etc.
    • Effective Date (required)
    • Subscriber Information — name, DOB, relationship to subscriber
    • Financial Details — copay, deductible, coinsurance %, out-of-pocket max
  3. Click Save.
Self-pay / Sliding Scale: When these coverage types are selected, subscriber and payer fields are hidden. Only effective date and financial terms are required.

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Coverage Priority (COB)

Coordination of Benefits (COB) is managed via Priority Order:
  • Priority 1 = Primary payer (billed first)
  • Priority 2 = Secondary payer (billed after primary adjudicates)
  • AHCCCS (Medicaid) is always the payer of last resort

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Editing a Policy

Click the pencil icon on a policy card to open the edit dialog.

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Terminating a Policy

  1. Click Terminate on a policy card.
  2. Confirm the termination date.
  3. The policy status changes to Terminated and is displayed with a terminated badge.

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Removing a Policy

Click Remove (trash icon) to soft-delete a policy. It will no longer appear in the active list. This action can be reversed by an administrator.

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Running an Eligibility Check

Phase 1 Note: Only manual entry is supported. Real-time 270/271 integration requires PM-15 (Clearinghouse) which is planned for a future phase.
  1. On a patient’s Insurance tab, find the policy you want to verify.
  2. Click Run Check in the eligibility status section of the policy card.
  3. Fill in the check result:
    • Check Type — Manual (default in Phase 1)
    • Eligible — toggle Yes/No
    • Response Status — Active Coverage / Inactive / Not Found / Error / Pending
    • Benefit Details (optional) — copay, deductible individual, deductible remaining
    • Next Check Due — date to schedule the next verification
    • Request Trace ID — reference number from clearinghouse (optional)
  4. Click Save Check.
The eligibility result is immediately displayed on the policy card and a pm_eligibility_verified event is published for downstream workflows.

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Reading Eligibility Status on Policy Cards

Each policy card shows:
  • Eligible badge (green) or Ineligible badge (red/amber) based on the latest check
  • Last checked date and time
  • Next check due date (amber warning if overdue)

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Coverage Gap Alert

An amber alert banner appears at the top of the Insurance tab when:
  • The patient has no active policies, OR
  • The latest eligibility check for any policy shows ineligible AND the next check due date has passed

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Dual-Eligible Patients (Medicare + Medicaid)

When a patient has both a Medicare policy and a Medicaid (AHCCCS) policy:
  • Set Medicare as Priority 1 (primary)
  • Set Medicaid as Priority 2 (secondary / payer of last resort)
  • An informational callout appears in the policy form when dual-eligible status is detected

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Self-Pay / Sliding Scale Workflow

  1. Add a policy and select Coverage Type = Self Pay or Sliding Scale.
  2. Subscriber and payer fields are hidden (not required for self-pay).
  3. Enter the agreed copay or sliding scale amount in the Copay field.
  4. Eligibility checks can still be recorded manually to document self-pay status.