Understanding eligibility and benefits is essential for accurately estimating patient costs within Rivet. By integrating patient-specific benefit information, Rivet enables healthcare providers to create informed estimates, ensuring clarity and transparency for both providers and patients. This guide outlines how to access and interpret eligibility information, configure benefit settings, and utilize this data to enhance the estimation process.
1. Accessing Eligibility
To access eligibility in Rivet, navigate to Patients > Eligibility from the top right corner. This section allows users to check a patient's specific benefit information by clicking "Check Eligibility." The returned benefit values are crucial for determining the cost implications of services for patients.
2. Checking Eligibility and Required Information
From the eligibility page in Rivet, you can click check eligibility to find out specific benefit information for a patient. These benefit values that are returned determine the cost of a particular procedure to a patient. To be able to check benefits for a patient we need to know some specific information to return an accurate eligibility.
Added to the patient's profile in Rivet
Patient Name
Patient Birthdate
Insurance company
Subscriber ID unique patient number with the insurance
Additional selection when creating an eligibility check
Provider performing the service
Specific service type: what type of service is being performed
Place of service code: where the service is being performed
3. Understanding Returned Benefits
The benefits that are returned will be separated out onto their own tab within an eligibility check.
Deductible: A deductible is the amount you pay for health care services before your health insurance begins to pay. For example, if your deductible is $1,000, your plan won’t pay for some services until you’ve paid $1,000 out-of-pocket for covered healthcare services.
Out-of-Pocket Maximum: This is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit does not include your monthly premiums or anything you spend for services your plan doesn’t cover.
Copay: A copay, or copayment, is a fixed amount you pay for a healthcare service, usually when you receive the service. The amount can vary by the type of service. For example, you might pay $30 for a doctor's visit or $50 for a specialist visit.
Coinsurance: is your share of the costs of a healthcare service, calculated as a percent of the total cost of the service. It usually kicks in after you've met your deductible. For example, if the health insurance company's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. The health insurance pays the rest.
Limitations: limitations on particular services such as a patient may be limited to the number of times insurance will cover physical therapy in a given year.
Original: the raw data that is transmitted from our eligibility vendor this tab is useful for diagnosing responses from payers or for looking at information that is not present in the other tabs
4. In-Network vs. Out-of-Network Benefits
After creating an eligibility check for a patient you can click on the specific eligibility to see more details of the benefits that are returned. Benefits will be returned for both in-network and out-of-network.
Note: Rivet does not determine whether the provider on the eligibility check is in-network or out of network we default to displaying in-network benefits.
In Network
Definition: Healthcare providers that have a contract with your health insurance company to provide services to plan members at predetermined rates.
Costs: Generally, using in-network providers costs you less out-of-pocket because your insurer covers a higher portion of the costs. Many plans cover preventive care at 100% when you see an in-network provider.
Benefits: Besides lower costs, in-network providers also handle billing the insurance company directly, which can save you some administrative hassle.
Out of Network
Definition: Healthcare providers that do not have a contract with your health insurance plan.
Costs: When you see an out-of-network provider, you typically pay more out of pocket. Some services may not be covered at all, leaving you responsible for the full cost.
Benefits: The primary reason to see an out-of-network provider is if they offer specialized care not available within the network or if you are seeing a provider of personal preference who is not in-network.
5. Configuring Benefit Settings
Benefit settings offer further customization and can be adjusted by navigating to "Account Settings" > "Estimates" > "Benefits". These settings allow for the configuration of Service Type Code exceptions, provider tiers, and benefit selection, enabling more accurate estimates and tailored benefit mappings.
Service Type Code (STC) Exception: Customize STC mapping at the payer level to enhance estimate accuracy by selecting the most specific service type for a given payer insurance product place of service treatment type and code.
Provider Tier: Assign providers by the payer to different tiers (Tier 1, Tier 2, or Out-of-network), or set provider type primary care physician or specialist by the payer.
Benefit Selection: Choose between the higher or lower copay or coinsurance rates when multiple options are returned for the same service type code, ensuring the best financial option is selected.
If you have any additional questions about appointments in Rivet feel free to chat in or email support@rivethealth.com
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