Eligibility and Benefits

Eligibility is updated on a daily, weekly, semi-monthly and/or monthly schedule as it is received from the health plans. Reconciliations are performed using Eligibility Manager software. Eligibility is also updated as needed when authorizations or claims are received for members not in the system. A detailed eligibility list is posted monthly for each Primary Care office and/or health center. Our provider web portal also posts current member lists for each office to utilize.

Staff configures benefit tables for each health plan benefit option to identify exclusions and provide co-pay information for each service. This information is integrated to ensure accurate authorization and claims adjudication processes.