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Insurance Verification & Electronic Eligibility

Vinesh V V
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Adding Insurance to a New Patient

Accurately adding and verifying a patient’s insurance is critical to ensuring proper billing, eligibility validation, and accurate treatment estimates. A consistent workflow allows your team to confidently collect and verify insurance information while minimizing errors and delays.

This guide outlines the recommended process for adding and activating patient insurance while maintaining data accuracy and efficiency.

 

 

Step 1: Add Insurance to Patient

Add New Patient

Begin by creating a new patient record in CareStack.

(Reference: Add a New Patient in CareStack refer to Add an Insurance Plan to a Patient)


Add Insurance Plan to Patient

Click Add Insurance

Enter subscriber details:

  • Select Self or add a Responsible Party (RP)
  • Enter Subscriber ID or SSN (if known)
  • Add all available insurance information in draft mode

Insurance Details:

NOTE: For insurances using SSN as the Subscriber ID please enter it under Subscriber ID without the dashes



Required Fields:

  • Subscriber ID  🞹
  • Effective Date  🞹
  • Employer: OPTIONAL *but helpful if this is common amongst your patient base
  • Carrier  🞹
  • Plan  🞹

Click Save


 

⚠️ Important:

Ensure the insurance is saved in Draft Status.

Do NOT click Mark Insurance as Verified at this stage. Doing so before all information has been fully verified may cause confusion within the office and is not recommended. Insurance should only be marked as verified after all details have been confirmed.

It is best practice to ask patients to upload their insurance card via the patient portal or send via text/email. This will ensure all details are accurate.

 

Topics Covered

Step 2: Verify Patient Information

Verify the patient’s insurance coverage details using one of the following methods:

  • Login to the corresponding Insurance carrier portal
  • Call the carrier for Phone verification
  • Request a Fax documentation 

This ensures that all information entered is accurate before finalizing the insurance.

Note: Best Practice to save referencing documentation in the patient’s document center 



 

Step 3: Navigate to Patient Insurance Screen

  • Navigate to the patient’s Insurance screen
  • Add in all verified information

 

Tip:

When entering verified details, click the information (ℹ️) icon to review additional plan details and confirm the correct plan selection.


Step 4: Mark Insurance as Verified

  • Click Mark Insurance as Verified

⚠️ Important:

Only select Mark Insurance as Verified after all insurance details have been fully confirmed through verification (portal, phone, or fax). Marking insurance as verified too early can lead to incorrect plan selection, inaccurate benefit information, and workflow confusion within the office.

The insurance will move into Pending Verification status, indicating that additional benefit details still need to be completed.


 

Step 5: Complete Patient Benefit Information

Navigate to View

  • Click View on the patient’s insurance

Edit Patient Information

  • Update Exclusions and Limitations 
  • Edit Patient Benefits
  • Filter by code or category
  • Update “Benefit Remaining” Yes / No
  • Save

Note: Updates here will directly impact fee estimates

  1. Navigate back to Plan Details
  2. Select Edit Patient Benefits

 

⚠️ Important:

Please note: Best practice is to only edit the Patient Benefits Remaining in this section, as modifying plan details here may affect all patients linked to the plan.

 

Enter Benefit Details

  • Add Family / Individual Maximum Remaining
  • Add Family / Individual Deductible Remaining
  • Add any relevant Plan Notes at the bottom for future reference (applies to all patients with this plan assigned)

Please note: Information above populated by the carrier to eEligibility will need to be manually entered in the system. Claims pending are not reflected in the electronic response.

 

Step 6: Save and Activate Insurance

  • Click Save and Update Eligibility

Once completed:

  • The insurance is now Active
  • Patient benefits are updated
  • The plan is ready for accurate billing and treatment planning

Topics Covered:

TIPS / TOOLS

  • Always verify all insurance details before marking it as verified
  • Avoid editing plan-level details from the patient screen
  • Use Plan Notes in the plan details to document important plan-specific details for future visits

The Ideal Insurance Workflow

When your team follows a standardized insurance process, verification becomes a seamless and proactive part of the patient experience.

Practices that follow these best practices typically experience:

Fewer claim denials
More accurate patient estimates
Improved billing efficiency
Reduced delays in payment
Better financial transparency with patients

A consistent insurance workflow ensures every patient is properly verified before treatment, supporting both operational efficiency and a high-quality patient experience.


eEligibility for Existing Patients

Ensuring that insurance information remains accurate for existing patients is essential for proper billing, treatment planning, and patient communication. As insurance benefits can change frequently, it is critical to verify eligibility on a recurring basis.

CareStack’s Electronic Eligibility (eEligibility) feature allows practices to efficiently verify insurance details directly through the clearinghouse, helping teams stay up to date with the most current patient benefit information.

Best Practice: Automate eEligibility

While eligibility can be checked manually, best practice is to enable automatic eEligibility to ensure patients are verified prior to their appointments.

How to Update Insurance eEligibility Settings

  • Navigate to Lists > Insurance Eligibility List
  • Click on the Settings button.

  • Select the Electronic Eligibility tab
  • Click Edit.

 

Configure Trigger Criteria

“Patients with pending eligibility who have appointments in next 7 days”

Note: This 7-day lead time allows for proactive verification and provides a sufficient buffer to resolve any coverage issues before the patient arrives.

Configure Eligibility Settings

You can configure eEligibility at either the Account Level or Location Level.

  • Enable the required practice locations
  • Select the Default Provider for eEligibility Request
  • Choose the Default Billing Provider
  • Select the Service Code: 35 Dental Care is recommended
  • Click Save once configuration is complete

Note:  If the primary appointment provider is a hygienist, the system will use the default billing provider to perform eEligibility


Review the Insurance Eligibility List

Access Insurance Eligibility List

  • Navigate to the Front Office Dashboard
  • Hover over the Lists tab
  • Select Insurance Eligibility List

Review Pending Eligibility

  • By default, you will land on All Insurance with Pending Eligibility
  • Switch to Insurance with Electronic Eligibility to identify patients requiring attention

Manual eEligibility

Only required when the carrier does not offer electronic response or was not picked up during the automated sync.

Step 1: Initiate Eligibility

  • From Insurance with Electronic Eligibility tab
  • Select the appropriate patient(s)
  • Initiate e-Eligibility

You will receive a notification once the process has started.


Step 2: Review Result

Once verification steps are completed:

Scenario A.)

If verification has returned an eEligibility response:

Two options will appear in the patient’s Insurance Overview Page:

  • Check for Mismatch
  • Show Details of eEligibility Response


 

Check for Mismatch

  • Identifies discrepancies in:
    • Patient demographics
    • Plan details
  • CareStack will display suggested updates next to each field
  • You may:
    • Update individual fields
    • Update all fields at once
    • Ignore fields if needed

 

Show Details of eEligibility Response

  • Displays all information returned from the payer
  • Includes eligibility status, benefits, and plan details

 

Step 3: Finalize Eligibility

  • Review all returned information
  • Make necessary updates

  • Click Save and Update Eligibility

 

Scenario B.) 

If verification does not produce an eEligibility response, check for “E.Failure”

  • Click “E.Failure” and determine what information needs to be corrected.
  • Correct any required information in the patient’s account
  • Follow steps to process eEligibility Manually

 

Scenario C.)

If the payor does not support Electronic Eligibility:

The Insurance Requiring Manual Eligibility tab includes insurance plans that require manual eligibility verification. This involves contacting the carrier or accessing their portal and updating eligibility based on available details.
 

 

The Ideal Eligibility Workflow

When your team consistently uses Electronic Eligibility, insurance verification becomes a proactive and automated part of your daily workflow.

Practices that follow this process typically experience:

Fewer claim denials
More accurate patient estimates
Reduced manual verification time
Improved front office efficiency
Greater confidence in insurance data

A standardized eEligibility workflow ensures that patient insurance is always up to date, supporting both operational efficiency and a more transparent patient experience.

 

Topics Covered

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