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Eligibility Verification
Quadax offers a digital service that helps healthcare providers check a patient’s insurance coverage quickly and accurately. This service is called the Eligibility Verification via API, and it’s designed to make sure patients are covered before services are provided—saving time, reducing billing issues, and improving the patient experience. This tool supports both standard eligibility checks and optional, advanced capabilities such as insurance discovery.
Key Features
Insurance Coverage: Verifies if a patient has active insurance.
Insurance Discovery: If no insurance is found, it can search for any active coverage the patient might have.
Demographic Repair: If the patient’s name, birthdate, or other details are incorrect, it can automatically correct them and retry the request.
MBI Assist: If a valid MBI is not present in the request to Medicare, it can attempt extra steps to obtain the MBI.
Additional Payer Coverage: Detects if the patient is enrolled in Medicare Advantage, Medicaid Managed Care, or other specific plans.
Alerts for Issues: Provides helpful rules & alerts like if the patient’s coverage is inactive, if Medicare is secondary, or if the patient is enrolled in hospice care.
Automatic Retries: If the insurance company is temporarily unavailable, the system can try again automatically.
Tracking: Each request can be tracked with a unique ID, making it easier to resolve issues if something goes wrong
Settings
Client feature transaction settings control whether a specific feature is triggered during an eligibility transaction, provided the relevant conditions are met. For API requests, these settings are determined by a combination of database values tied to the client, along with any applicable overrides specified in the HTTP headers.
Common Business Rules
A variety of business rules can be returned to determine if the patient has active coverage or not, along with additional rules that offer further insight into the patient’s insurance details.
Examples of commonly returned rules include:
146 – Active Coverage
183 – Insurance Discovery - Active Coverage Found (if enabled)
32 – Subscriber Name Mismatch
149 - Subscriber Date of Birth Mismatch
43 – Subscriber Ineligible
185 – Insurance Discovery – No Active Coverage Found (if enabled)
Eligibility Payers
Returns a list of payers and payers by code that are available for real-time eligibility checks. Uses include:
Denial Avoidance
Quadax’s Denial Avoidance Product applies machine learning to your organization’s historical claims and remittance data to identify claims at high risk of denial. By flagging potential issues early, staff can quickly address various coding, documentation, or administrative errors, reducing costly rework, accelerating reimbursement, and strengthening cash flow. Delivered via API, this capability integrates seamlessly into your workflows and is part of Quadax’s expanding suite of AI-powered revenue cycle solutions.
Claim Validation
The Quadax Claim Validation API is a service which can be used for integration with the Quadax Edits engine (Edits as a Service). With this product enabled, an Electronic Medical Record (EMR) can submit an API “Request” with either a full or partial embedded 837 and can validate the claim(s) against the robust Quadax Edits library. Specific information surrounding any erred data will be fed back to the EMR, where users can react and update the patients’ information real-time while keeping the EMR the source of truth.
Coming Soon - Q4 2025
Prior Authorization
Coming Soon - Q4 2025