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Disclaimer: All features on this page that require automated eligibility and prior authorization checks depend on a separately purchased third-party integration. Please contact your customer success manager for more informaiton.

Insurance Eligibility and Prior Authorization

In OAI, the automated Insurance Eligibility and Prior Authorization is done through the integration with a third-party solution.

Adding Insurance Payers to the Organization​

  • Click on Organization on the left panel and open the respective organization details page

  • Within the Organization detail page, click on RIS. It will expand and display the Insurance Payer

  • Click on Insurance Payers. It will open the insurance payers where the user can add new insurance payers, edit existing insurance payers, and delete existing insurance payers

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  • Click on the + icon to add a new insurance payer. It will open the Add new insurance payer drawer.

  • Search for the insurance payer name you wish to add. It will search the list of insurance payers supported by the third-party integration, along with the ID for the corresponding insurance payer.

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  • Select the Insurance payer name and fill in the other details like Financial Type, Address, and Contact Details, then click on Create to create this payer

  • Once the payer is saved, it will be reflected in the Insurance Payers list displayed

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Editing/Deleting a Insurance Payer Record​

  • When you hover over the Payer record on the Payer list page, you will see the Edit and Delete icon

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  • When you click on the Edit icon, the Edit Payer drawer will open

  • Users should be able to edit the details and, on clicking the Update button, the details would be saved

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  • To delete a Payer record, click on the Delete icon

  • On clicking the Delete icon, the corresponding Payer record would be deleted, and it would disappear from the Payer list

Adding Coverage for a Patient​

A patient’s coverage information can be added from the Patient Info page, under the Coverage section.

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  • On clicking the + button, the Add New Coverage drawer will open.

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  • While entering the Payer Name, the user can search and select from the list of payers added to the organization.

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  • Set the Coverage status from the top of the Add coverage page.

  • Fill in the patient’s coverage details, including the Payer Name and Coverage Effective date range.

  • By default, the Member relationship to the patient is selected as “Self,” and the Member Name is prepopulated with the Patient’s Name.

  • The user can change the Member relationship by clicking the dropdown and selecting the appropriate relationship.

  • Make necessary changes by selecting the relationship to the patient and searching for the Member name.

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  • Once the Member is selected, the Member name field would be populated with the selected record.

  • If the Member is not present in OAI, then the Member record must be created in OAI.

  • Click on Add New to create a patient record for the Member.

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  • Once the new Member record is created in OAI, the user should be able to select the relationship and populate the newly created Member record.

  • Enter the Member ID and Group Number details.

  • The user can select the Employer name by searching from the list of employers in OAI.

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  • If the Employer Name is not present in OAI, then the Employer record can be created in OAI.

  • Click on Add New to create an Employer record for the Member.

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  • Once the new Employer record is created in OAI, the user should be able to select it and populate the newly created Employer record.

  • The user can optionally add the Member’s insurance card image.

  • Once the user is done adding all the details, clicking the Save button will save the coverage information.

  • Once the patient’s coverage information is saved, if the organization has subscribed for the eligibility check product, then—irrespective of the value selected under the Eligibility coverage status field— the third-party eligibility check API will be called with the entered information.

  • The API results will come instantly and update the coverage details.

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  • If the coverage is active, it will automatically update the Eligibility coverage status field, and the coverage details card will be updated with a link to the eligibility report.

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  • If the coverage is inactive due to incorrect information or if there is no active coverage for the user, it will be instantly visible on the screen as a toast message, and the subsequent coverage details card is updated.

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  • Whenever any of the coverage-related information is updated, the eligibility check API will be called again to reflect the latest status of the coverage.