NHCX Check Eligibility Coverage

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.

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.