These changes are currently available in Beta. These changes will be live in first week of Jan 26
This document walks through how member eligibility can be managed for CCP programs, including updates to the Member List, Filters, Member Insurance Tab, and Member Eligibility Tab.
1. Member List Enhancements
The Member List has been enhanced to provide better visibility into eligibility data.
1.1 New Columns Added
Two new columns have been introduced:
Data Source From
Displays the source of the member eligibility data.
Possible values:
Availity – Eligibility data retrieved from Availity
Other – Eligibility data entered or sourced outside Availity
Last Updated
Displays the date when the member eligibility data was last updated/refreshed from Other/Availity
2. Member Eligibility Filters
New filter options allow users to identify and manage members based on eligibility data availability.
2.1 Filter Location
Navigate to Filters
Go to Demographics → Eligibility
2.2 Eligibility Filter Options
Option 1: Eligibility = Yes
When Yes is selected, members can be further filtered by:
Eligibility Type
Primary
Secondary
Data Source From
Availity
Other
Eligibility Updated
Filter members whose eligibility was refreshed within X number of days
Option 2: Eligibility = No
When No is selected, members can be filtered based on:
Primary or secondary eligibility not available
Errors encountered when attempting to refresh eligibility from Availity
3. Member Eligibility Tab Availability
All CCP members will have the Member Eligibility tab available under View All.
However, eligibility data will only be populated if a Primary Insurance is added in the Member Insurance tab.
4. Member Insurance Tab Updates
Updates have been made to the Add/Edit Insurance form to support eligibility management.
4.1 New Fields Added
Two new fields are now available:
Availity Payers
Dropdown field to select the appropriate Availity payer
Use for Member Eligibility
Checkbox to indicate which insurance should be used for eligibility checks
4.2 Selecting an Availity Payer
If the insurance is sourced from Availity, select the appropriate Availity Payer from the dropdown.
If no Availity payer is selected when saving:
A member eligibility record is still created
The Data Source From field defaults to “Other”
4.3 Managing Multiple Insurances
A member may have:
One primary insurance
Multiple secondary insurances
However, only one insurance (primary or secondary) can be used for member eligibility at a time.
To support this:
A “Use for Member Eligibility” checkbox is added at the bottom of the form
Only one insurance record can have this checkbox enabled at any given time
5. Member Eligibility Data Population
Once all mandatory insurance fields are completed and the form is submitted:
5.1 When Availity Payer Is NOT Selected
The Member Eligibility tab is created
Some insurance details are prepopulated
Other eligibility sections remain blank
Data Source is shown as Other
5.2 When Availity Payer Is Selected
Eligibility data is fetched from Availity
Relevant insurance and eligibility details are automatically populated in the Member Eligibility tab
6. Insurance Plan Information
The Insurance Plan Information section displays high-level plan details sourced from the Member Insurance record.
6.1 Initial Data Population
The following details are initially fetched from Member Insurance:
Plan Name
Member ID (Subscriber ID)
6.2 Viewing and Editing Additional Details
Click the “More” link to view additional insurance plan details.
A side panel opens with expanded information.
Click the Edit (✏️) icon within the side panel to make updates.
7. Benefit Plan Details
The Benefit Plan Details section is used to manage benefit-related information such as:
Copay
Coinsurance
Deductible
7.1 Auto-Calculated Fields
Based on the benefit details entered or fetched:
Deductible Balance
Out-of-Pocket Remaining
These values are automatically calculated using the available data and do not require manual input.
8. Estimated Monthly Cost
The Estimated Monthly Cost section displays estimated contractual rates based on benefit details and CPT charge codes.
8.1 What Is Calculated
Estimated monthly contractual rates when paying toward:
Deductible
Coinsurance
These calculations are based on:
CPT charge codes associated with the member’s program practices
Benefit information fetched from Availity
9. Managing CPT Charge Codes
9.1 Pre-Populated CPT Codes
Some practices already have CPT charge codes pre-populated by default.
If CPT codes are missing or need updates, program admins or program managers can manage them manually.
9.2 How to Manage CPT Charge Codes
Navigate to Programs
Select the relevant program
Click on Practices
Click Edit on the desired practice
Scroll to the bottom to find the CPT Charge Codes section
9.3 Eligible for Specialist
A checkbox labeled “Eligible for Specialist” is available
If selected:
Specialist copay will be considered when fetching eligibility data from Availity
9.4 Impact on Member Eligibility
Once CPT charge code rates are available:
Estimated Monthly Contractual Rates
Minimum
Maximum
Values for Deductible and Coinsurance are displayed in the Member Eligibility tab
10. Summary of Findings (Auto-Generated)
Based on the available benefit details, the system automatically generates a Summary of Findings for the following scenarios:
Copay Only Available
Copay with Deductible Balance < $500 and > $0
Member 100% Covered
Deductible Balance ≥ $500 with Coinsurance
11. Text Snippets for Other Scenarios
For scenarios outside the four auto-generated cases, teams can use Text Snippets.
11.1 Creating Text Snippets
Navigate to Profile Settings (top-right corner)
Go to Settings → Text Snippet
Create and save reusable templates
11.2 Using Text Snippets in Summary of Findings
In the Summary of Findings edit/add section:
Type “@”
Select the desired snippet
The template content is automatically inserted
Teams can then:
Use the available member eligibility data
Customize and complete the summary
12. When Insurance or Eligibility Changes
If a member’s insurance or eligibility information changes:
12.1 Refreshing Eligibility Data
For Data Source = Availity
Click Refresh
For Data Source = Other
Click Add Update
12.2 Version History
Each refresh or update:
Creates a new Member Eligibility record
Preserves previous records
Teams can view historical versions using the Last Updated dropdown
13. Secondary Insurance Eligibility
13.1 Adding Secondary Insurance
Once a secondary insurance is added in the Member Insurance tab:
The team must click “Add Secondary Insurance” in the Member Eligibility tab (first time only)
13.2 Behavior
This creates a secondary eligibility record
The workflow and behavior are similar to primary insurance eligibility
All rules around data source, refresh, and history apply equally
14. Availity Refresh Errors & Error Visibility
When refreshing member eligibility data from Availity, the system captures and surfaces any errors encountered during the refresh process.
14.1 Error Display in Member Eligibility
If an error occurs while refreshing data from Availity:
The error message is captured
The error is displayed directly within the Member Eligibility tab
16.2 Filtering Members with Availity Errors
Teams can filter members to identify those with Availity refresh errors
This enables faster follow-up and issue resolution
16.3 Member List Status for Failed Refresh
In cases where the Availity refresh fails:
The Last Updated column in the Member List displays a Failed status
This provides immediate visibility without needing to open the member record
17. Eligibility Status Changes
Eligibility status changes are automatically reflected when updated data is received from Availity.
17.1 Loss of Eligibility
If a member loses eligibility:
The updated status is reflected in:
Member Eligibility Tab
Member Overview Section
18. Eligibility Status Definitions
The system supports the following three eligibility statuses:
18.1 Active
Member currently has active insurance coverage
Benefit and plan details are available
18.2 Lost Eligibility
Member previously had coverage
Coverage is no longer active based on the latest eligibility refresh
18.3 Self Pay
Member does not have active insurance coverage
Costs are expected to be paid directly by the member
19. Default Status Scenarios
19.1 Data Source = Other
When Data Source From is set to Other:
The default eligibility status is “No Coverage Info”
19.2 No Benefit Plan Details from Availity
If eligibility data is refreshed from Availity, but:
No benefit plan details are returned
The eligibility status is set to:
“No Plans Exist”
Few Things to Highlight:
Auto update of member eligibility right now happens only when availity payer insurance plan is added in the member insurance.
System does not add member tags when the member losses eligibility