> ## Documentation Index
> Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt
> Use this file to discover all available pages before exploring further.

# Insurance & Eligibility Verification — User Guide

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

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

***

## Prerequisites

You need the following permissions to use these features:

| Permission            | What it allows                                          |
| --------------------- | ------------------------------------------------------- |
| `pm.insurance.view`   | View patient insurance policies and eligibility history |
| `pm.insurance.manage` | Add, edit, terminate, or remove insurance policies      |
| `pm.eligibility.run`  | Record eligibility check results                        |
| `pm.payers.view`      | View the payer directory                                |
| `pm.payers.manage`    | Add, edit, or deactivate payers                         |

Contact your administrator if you are missing any of these permissions.

***

## 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**.

### 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).

### Removing a Payer

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

***

## 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.

### 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.

### 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

### Editing a Policy

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

### 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.

### 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.

***

## 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.

***

## 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)

### 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**

***

## 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

***

## 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.