Real time eligibility (RTE) checks allow pharmacies to instantly verify a patient’s insurance eligibility (on the medical benefit), streamlining the claims process and enhancing accuracy in billing.
How Real-Time Eligibility Checks Work
When RTE is enabled, the platform will automatically verify a patient's medical insurance coverage with their listed payer, confirming eligibility in real time. This verification helps ensure that claims are processed more smoothly, reducing delays due to missing or inaccurate information. For most payers, this automated check provides real-time feedback, making it a useful addition to the pharmacy workflow. RTE has three possible results:
- Eligible Patient information is accurate and the patient has coverage with this payor.
- Ineligible Patient information may not be correct or the patient is not covered by this plan.
- Failed RTE did not happen. A communication error occurred. We recommend trying again.
What RTE Is Not
RTE checks for the existence of coverage. It does not confirm that a service will be covered and it does not make you aware of any patient responsibility for the service. In other words, RTE lets you know that the patient does or does not have insurance coverage with a given plan but it does not tell you what will be covered or how much of a service will be covered.
What to Do if an RTE Check Shows Patient Ineligible
While RTE significantly boosts accuracy, it isn’t foolproof. The reason for this is that some plans don't allow for RTE. If an RTE check fails it is possible the patient is still covered by that plan, so if the patient is confident in their coverage, here are the steps a pharmacist or technician should follow:
- Verify Insurance Information: Double-check that the patient is showing you their most recent card and that the insurance details in the patient’s profile are correct and up-to-date. If correct, go to step three.
- Make Any Necessary Corrections: Update the patient’s insurance information if errors are identified.
- Proceed with Workflow: Once insurance information is confirmed, continue with the usual workflow to ensure timely claim submission.
If you have any doubt about whether or not a patient has insurance it is best to contact the insurance company directly to confirm. We also recommend keeping a patient's credit card information on file so that, in the event a claim gets denied or the patient's insurance information is not valid, you will be able to bill for the services delivered.