Eligibility Inquiry Walkthrough

Overview
Eligibility Inquiries are the most common transaction submitted in the HEALTHeNET (HeN) application. Following is a step by step walkthrough of performing an eligibility inquiry.

Quick Notes

• Some payers have different minimum submission requirements than others.
• Required fields for Nova:
• Member Number
• Member First & Last Name
• Date of Birth
• Eligibility Date
• Service Type
• Required fields for New York Medicaid:
• Provider NPI
• Member Number
• Eligibility Date (Must be for the current month)
• Service Type
• All other payers require two of the following fields:
• Member Number
• Member First & Last Name
• Date of Birth
• Social Security Number
• Additional information can be found in the Eligibility Inquiry Tip Sheet

Submitting a Basic Eligibility Inquiry (Nova)

1. Click on Eligibility Inquiry in the HEALTHeNET menu

2. Select the Payer from the drop-down

3. Enter the Member Number, Member First & Last Name, and DOB
Note: Eligibility Date & Service Type default to Today and General Benefits

4. Click on the SUBMIT button

Submitting a Basic Eligibility Inquiry (NY Medicaid)

1. Click on Eligibility Inquiry in the HEALTHeNET menu

2. Select the Payer from the drop-down

3. Enter the NPI for the requesting provider and the Medicaid Member Number
Note: Eligibility Date & Service Type default to Today and General Benefits

4. Click on the SUBMIT button

Submitting a Basic Eligibility Inquiry (All Other Payers)

1. Click on Eligibility Inquiry in the HEALTHeNET menu

2. Select the Payer from the drop-down

3. Enter the Member Number and DOB or the Member First & Last Name and DOB or the SSN and DOB
Note: Eligibility Date & Service Type default to Today and General Benefits

4. Click on the SUBMIT button

Submitting a Basic Eligibility Inquiry (Dependents)

1. Click on Eligibility Inquiry in the HEALTHeNET menu

2. Select the Payer from the drop-down

3. Enter the Subscriber Member Number, Dependent First & Last Name and DOB
Note: Eligibility Date & Service Type default to Today and General Benefits

Note: Dependent information fields may be in a separate section

4. Click on the SUBMIT button

Submitting a Basic Eligibility Inquiry (All Payers)
Note: Commonly referred to as All In List and excludes Nova and Medicaid because of submission volume restrictions

1. Click on Eligibility Inquiry in the HEALTHeNET menu

2. Select the All Payers option from the drop-down

3. Select a Provider from the provider list located under the Payer drop-down


4. Enter the Member Number, Member First & Last Name and DOB
Note: Eligibility Date & Service Type default to Today and General Benefits

5. Click on the SUBMIT button

Verifying the Returned Data
When an inquiry is submitted, there are three possible results, depending on the inquiry options selected and the outcome of the returned results. The Benefit Detail page, the Response Summary page, and the Rejected Result page.

Request to Single Payer
If the request was for a single payer, the benefit response screen will be returned.

All Payers Option Selected in the Drop-Down
If the request was for All In List, the response summary screen will be returned. The summary will contain both the positive and negative responses from the payers. An individual positive response is then selected to view the details.

Reject by the Payer
If the inquiry returns a rejected response from the payer, there should be an accompanying explanation.

Conclusion
This document covers the vast majority of use cases for the Eligibility Inquiry screen and the required fields for each. There are additional request fields included on the inquiry screen, however they are all optional.