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Purpose of the Eligibility and Benefits Inquiry
Eligibility and Benefits inquiries are used to inquire about the health care eligibility and benefits associated
with a subscriber or dependent and to confirm their insurance eligibility.
Completing the Eligibility and Benefits Inquiry Form:
Indicated Payer (Required)
Select payer from the drop-down list. You can either select a specific payer or "All in List".
Subscriber (Required)
Two of the following fields are required:
If you do not enter the required information, the submit button will be 'greyed' out until all required fields are entered. Click on the "Information" icon for required fields for each section and additional information.
If the patient is a Dependent (the default is the subscriber). The following fields are required:
If you do not enter the required information, the submit button will be 'greyed' out until all required fields are entered. Click on the "Information" icon for required fields for each section and additional information.
Eligibility Date
If you do not enter an Eligibility Date the current date will be used.
Eligibility Response Page
How to Print the Eligibility Response
The Eligibility Response is its own "Printer Friendly Page" and can be printed directly from your browser.
Select the "Print Result Button" on the top right of the screen and select the benefits you wish to print.
Helpful Hints for All Payers
The Eligibility Date defaults to today's date, but the date can be changed to a past date or up to 30 days in
the future, for some payers.
The date displayed in the upper left-hand corner of the Eligibility Response page indicates the date and time
the Eligibility request was made. This is NOT the member's Eligibility date. Look to the Plan Benefit Detail
section for the member’s Eligibility date.
HEALTHeNET payers are providing "Other Insurance" information which is member self-reported. The accuracy of
this data CANNOT be guaranteed, but rather serves as an indicator that there may be other insurance coverage
for the member. It is strongly recommended that any "Other Insurance" information returned on an Eligibility
Responses be verified by the user.
Payer Specific Helpful Hints
Fidelis Care's Processing Rules for HEALTHeNET Eligibility
Eligibility Date
Enter a Date of Service. Eligibility information for Fidelis members is available for the past 24 months
using the HEALTHeNET application. Members may change coverage levels often and the benefit information
returned will be based on the eligibility date entered on the inquiry screen.
The effective and term date provided do not necessarily mean the member doesn't have other coverage
with us before or after those dates. If you need to confirm a date outside of the effective and term dates
provided, please do another inquiry using that date.
OB/GYN Provider Information
Members are not required to inform Fidelis who their OB/GYN is; therefore this information is rarely supplied.
COB Information
Fidelis does not actively collect or update COB information. When COB information is provided for a member
please note that it may not be accurate.
Member Not Found or Multiple Members Found
When a single member is found using the data entered, the program determines if the member has active coverage
for the Eligibility Date entered. If the member does not have active coverage for that date,
the following message will be reported:
"Reject reason: Patient Not Found. Follow up action: Correct and resubmit."
When the search criteria entered results in multiple members found, the program will then use the eligibility
date to narrow the results to one member. If multiple members are still found,
the following message will be reported:
"Reject reason: Duplicate Patient ID Number. Follow up action: Resubmission not allowed."
If you believe the member has coverage and you did not fill out all the search criteria fields available,
please do another inquiry with additional information. If you believe the information being reported is incorrect,
or need further information, please call our IVR system at 1-888-FIDELIS for a fax confirmation report.
Excluded Benefits
Dental, Family Planning, Pharmacy and Vision benefits are administered for our members by other plans.
For more information, please discuss these benefits with the member or call our provider call center
for a particular member.
Future Dated Inquiries
Providers are allowed to enter an eligibility date up to 30 days into the future from today's date.
This allows the provider to validate that a Fidelis Care member will have coverage within the next 30 days.
Future date functionality does not guarantee payment of claims, benefit coverage, or eligibility for services.
Requests received with an eligibility date past the 30-day window will be returned with an "out of range" response.
Independent Health Processing Rules for HEALTHeNET Eligibility
Please note: Eligibility information prior to 18 months will not be displayed on HEALTHeNET
The system is designed to return eligibility on members if they can be uniquely identified by at least two (2)
of the following pieces of information: last name and first name (1 piece) and one of the following:
member ID, date of birth, or social security number.
When member ID is supplied as one of the 2 pieces of
data shown above and the member can be uniquely identified, the information that is returned will be for the
member ID supplied. When member name and DOB are submitted the system will respond back with all policies associated
with that member (i.e. Member is subscriber on an Independent Health plan and a dependent on another
Independent Health plan, both plans will be sent back in the response).
PCP/Specialist Information
The only time you will not see the PCP/Specialist Indicator is if the member cost share is the same regardless of
the provider type.
Group Renewal Date
The group renewal date is now included in the Additional Information section of the Eligibility Detail screen.
Coordination of Benefit Information (COB)
Independent Health will return COB information if we have it on file.
Future Dated Inquiries
We will allow providers to enter an eligibility date up to 30 days into the future from the current date.
This will enable the provider to verify if a member will have a contract change within the next 30 days.
Allowing future date functionality "does not guarantee" payment of claims, contract benefits
or eligibility at the time services are rendered.
Preventive Services Guide
Independent Health has posted a Preventive Service Guide to assist in identifying services that are not
subject to member cost share. This guide is located under the links section.
Example:
: The Surgical benefit return has multiple benefits that map to place of service 11 (Office).
The 271 response will display 2 rows for "Place of Service: Office". There will be no other text available to
indicate the difference between the primary care physician and specialist. One line on the return will
indicate primary care physician and one line will indicate specialist if there is a differential in the
patients cost share. The lower patient cost share is for services received in a primary care physician's
office and the higher patient cost share is for services received in a specialist’s office.
NOVA Healthcare Administrators Processing Rules for HEALTHeNET Eligibility
Valid Matches:
Univera HealthCare Processing Rules for HEALTHeNET Eligibility
The system is designed to return eligibility on members if they can be uniquely identified by at least two (2)
of the following pieces of information (last name, first name (1 piece): Member ID, Date of Birth.
We recommend not to use a patients Social Security Number).
When a member is located the program determines if the member has ACTIVE membership for the Inquiry Date.
If the member was not eligible for this date when the program displays the message:
"Reject reason: Date of Service not within allowable inquiry period.
Follow up action: Correct and Resubmit."
If the member has active coverage for this inquiry date the benefit information
for this period of time is displayed.
We will allow providers to enter an eligibility date up to 30 days into the future from the current date.
This will enable the provider to verify if a member will have a contract change within the next 30 days.
Allowing future date functionality does not guarantee payment of claims, contract benefits or eligibility
at the time services are rendered.
When the search criterion yields multiple matches and is unable to resolve one and only one member with the
matching criteria then the "patient not found" message will be returned.
Univera Healthcare only allows one service type to be selected per request.
Benefit Detail for Behavioral Health services can be found under the following "Service Types":