---
title: "NHCX Check Eligibility Coverage"
description: "How to check a patient's policy coverage and eligibility before starting treatment, including Get Policies and Discover Policies."
date: 2026-08-21
lastModified: 2026-08-21
category: "nhcx"
author: "Dr. Umesh Bilagi"
beta: true
---

## Overview

Before treatment, you verify that a patient's policy actually covers the planned procedure. This is the **Check Eligibility Coverage** step. The system sends a `CoverageEligibilityRequest` to the payer and records the payer's response against the patient's workflow.

There are two ways to start:

- **Get Policies** — look up the patient's policies automatically using their ABHA number, mobile number, or member ID.
- **Discover Policies** — manually enter subscriber/beneficiary/policy details and run a **Discover** or **Validate** request.

## Where to find it

Open the patient's NHCX page and choose **Check Eligibility Coverage**. From there you can use **Get Policies**, **Discover Policies**, or fill the eligibility form directly.

## Step 1 — Get Policies

Use **Get Policies** when you want the system to pull the patient's existing policies.

1. Choose the **Identifier Type**: `AbhaNumber`, `MobileNo`, or `MemberId`.
2. Enter the **Identifier Value** (pre-filled from the patient record where possible).
3. Click **Get Polices**.

The results list each policy with its AbhaNumber, Member Id, Product Id, Payer, and Processor. Use the **Insurance Plan** action on a row to load that plan's benefits into the eligibility form.

## Step 2 — Discover Policies

Use **Discover Policies** when you already have the policy details.

1. Fill **Subscriber ID**, **Beneficiary ID**, **Policy Number**, and choose the **Payer** (or enter a participant code such as `1518@hcx` and click **Lookup**).
2. Select the **Doctor** and **Relationship**.
3. Click **Discover** to find policies, or **Validate Coverage Eligibility** to confirm the policy is valid.

## Step 3 — Eligibility form

The **Eligibility** section captures the request:

- **Service Start** / **Service End** — the treatment period.
- **Doctor** — the attending practitioner.
- **Priority** — request priority (default `Normal`).

The **Coverage** section captures the policy:

- **Subscriber Id (Policy Holder ID)** — the policy holder.
- **Beneficiary ID** — the person being treated.
- **Policy Number**.
- **Relationship** — how the beneficiary relates to the subscriber (default `Self`).
- **Purpose** — `benefits`, `auth-requirements`, `discovery`, or `validation`.

For a newborn, use the **Newborn (Baby of Parent)** section to enter the **Parent UHID (card-holder)**. See [NHCX Newborn Claim](/docs/nhcx-newborn-claim).

## Step 4 — Items

Add each procedure/service being requested via **+ Add Item**. For each item select:

- **Benefit Category** — loads the applicable product/service options from the insurance plan.
- **Product/Service** — the specific procedure.
- **Quantity**.
- **Stratification** and **Implant** codes, if the selected procedure requires them (the system warns but does not block if a required stratification/implant is not selected).

At least one item is required unless the purpose is `discovery` or `validation`.

## Common Issues

- **"At least one item is required"** — add at least one item (or set Purpose to discovery/validation).
- **"Subscriber ID / Beneficiary ID / Policy Number is required"** — these fields are mandatory; fill them or run Get Policies to populate them.
- **No procedures listed after choosing a benefit category** — the plan may have no mapped benefits; check the insurance plan data.

## FAQ

**Q: What is the difference between Discover and Validate?**
A: Discover asks the payer what policies exist for the given subscriber details. Validate confirms whether a specific policy number is valid for that beneficiary.

**Q: When should I use Get Policies vs Discover Policies?**
A: Use Get Policies when you only have the patient's ABHA/mobile and want the system to find their policies. Use Discover Policies when you already know the policy number and payer.

**Q: Do I have to enter items?**
A: Yes for `benefits` and `auth-requirements` purposes. For `discovery` and `validation` you can leave items empty.