Patients and families
Eligibility and insurance
Enter primary and secondary insurance, run a real-time eligibility check, read Coverage Active or Not Active, and fix member-ID problems before the visit.
Insurance on file
The Coverage card holds the carrier (from the live payer directory), member ID, group, subscriber, and relationship. Secondary insurance is a second block; coordination of benefits uses both.
Eligibility check
Check eligibility sends a real-time inquiry (Sefton Complete). The card reads Coverage Active or Coverage Not Active with the plan details returned by the payer (copay, deductible remaining, visit limits where provided). Insurance information is required before the check can run.
Fixing problems
- Member ID mismatch: the Member ID fix form re-runs the inquiry with the corrected number and updates the record.
- Coverage expired: the coverage-expired form captures the new card and re-checks.
- Verify payer on the directory chip means the payer name could not be matched to the directory; pick the correct payer.
Where else it appears
Eligibility status shows on the Sessions card before a visit, and the claim scrubber blocks a submission when coverage was Not Active on the date of service.
Frequently asked questions
When should I run eligibility?
Before the first visit and at the start of each plan year. Sefton also warns when coverage on file looks expired.