You're trying to vaccinate your patient, but the system is telling you the patient is Not Eligible. What's going on?

First, let's review something really important, but also very easy to forget, especially if you have an upset patient standing right in front of you.

VaxCare exists to decrease the risks associated with the traditional vaccine program, so all of our tools have been created to protect your practice -- and, as a result, your patient -- from receiving a bill whenever possible. We process nearly a million doses of vaccine a year, which means we know (and ask for) exactly what the insurance company wants in order to process and pay the patient's claim. Anytime their criteria is not met, you receive an alternate response from the Scheduler. 

What's going on behind a Not Eligible response?

Our Scheduler uses an insurance gateway service called Availity, which checks two very important things: 1) Does the patient have active insurance? and 2) Are they in network with VaxCare? If the answer to those two questions is yes, the patient is Eligible (or, more rarely, Eligible with Possible Patient Responsibility). If the answer to either of those two questions is no -- or if the patient's information is incorrect -- the patient is Not Eligible.

Does Risk Free guarantee my patient won't receive a bill?

As a reminder, an Eligible response is not a guarantee of payment on behalf of the patient, but it does mean that nothing about that patient's information indicates they should have financial responsibility for their vaccines.

That said, if a patient has any questions about their vaccine coverage, we always recommend they contact their insurance provider directly.

So I can't vaccinate my patient with a Not Eligible response?

Let's make something really clear right now: A Not Eligible response is not a clinical recommendation not to vaccinate. That's totally your call. That said, a Not Eligible response is an indication that something is wrong with the patient's information, and it's a recommendation to correct the information before administering a vaccine. Otherwise, either you or the patient is likely to end up with the bill.

So what do I do if my patient is Not Eligible?

Simply click on the patient's eligibility icon and follow the prompts the system is giving you. 

If the patient is out of network, change the method of payment to Partner Bill. You'll still vaccinate the patient, but your office will do all of the billing.

If the patient has expired or missing information, update the information and select "Save" to recheck eligibility. If the patient does not have, or refuses to give you, updated information, we recommend having the patient Self Pay for their vaccines in order to protect your office from undue liability. 

Can I check in a patient who is At Risk/Not Eligible?

The short answer is yes, as the system will not stop you from checking in an At Risk patient. That said, keep in mind that the only reason you're seeing a Not Eligible response is because we are attempting to correct the patient's information and protect your office from the start. Our system is here to help you, not to frustrate you (though we know it doesn't always feel that way!). 

Also, be sure to follow office protocol, as some of our partners have instituted policies to prevent staff from checking in patients that are At Risk/Not Eligible.

If you do submit a patient At Risk, keep in mind that we will do everything reasonably within our power to obtain the patient's correct demographic information and/or bill the patient for any outstanding deductibles. However, if the patient or insurance company does not reimburse VaxCare for an At Risk dose within our 90 day billing cycle, your office will be charged for the cost of the At Risk vaccine.

Still have questions? Reach out to our Customer Care team. We're happy to help! Message us directly by clicking on the blue Intercom bubble in the bottom right corner of your screen. Email us at help@vaxcare.com. Or call us at 1-888-829-8550.

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