Real-Time Insurance Eligibility & Benefits Checks
Check a patient's insurance eligibility and benefits in real time the moment an appointment is booked — and hand back a clear coverage report.
The workflow
The complete flow, exactly as it runs in the Workflow Builder. Scroll to explore, or use the zoom controls.
Requirements
Set up these connections in the Workflow Builder before importing or running this workflow.
The clearinghouse connection that sends the standard electronic eligibility request to the insurer and receives the coverage answer back in real time.
Used to receive the scheduling notification that triggers the eligibility check the moment an appointment is booked.
Provides backend access to read patient demographics (name, date of birth, member ID) needed to build the eligibility request.
About this workflow
Before a visit even starts, the front desk needs to know: is this patient covered, and what will they owe? This workflow checks insurance eligibility and benefits in real time — triggered the moment an appointment is booked — and hands back a clear, readable coverage report.
The problem
Verifying coverage is one of the most repetitive jobs in any clinic. Staff log into payer portals or call insurers one patient at a time, then retype what they find. It's slow, it delays check-in, and missed or stale coverage info is a leading cause of denied claims and surprise bills.
How it works
When an appointment is scheduled, a standard "new appointment booked" notification from the EHR (or a direct API call) kicks off the workflow. It reads the patient's name, date of birth, and member ID, then builds the standard electronic eligibility request insurers expect and sends it through Stedi to the payer in real time.
The answer that comes back is turned into a plain-English report — active plan, copays, deductibles, out-of-pocket maximums, and what's covered — ready to hand to the front desk or write back to the health system.
Why it matters
Coverage is confirmed in seconds instead of phone calls, so check-in is faster and patients get a straight answer about what they'll owe. Catching eligibility problems before the visit means far fewer denied claims and surprise bills down the line.
Who it's for
Front-desk and revenue-cycle teams who want eligibility checks to happen automatically at scheduling, and any system that needs a simple API to run a real-time 270/271 check.
How to build this workflow
Recreate it in the Workflow Builder by wiring these steps in order — or download it above and import it directly.
Step 1: Capture the Appointment
A booking comes in — a scheduling notification from the EHR, a patient-portal form, or an API call — carrying the patient and their insurance details.
Step 2: Pull Insurance Details
Read the patient's name, date of birth, and member ID out of whatever arrived.
Step 3: Build the Eligibility Request
Map those details into the standard electronic format insurers expect for a coverage check.
Step 4: Check With the Payer
Send the request through Stedi to the insurance payer in real time and get the coverage answer back.
Step 5: Read Back Coverage & Benefits
Turn the response into a clear report — active plan, copays, deductibles, out-of-pocket, and what's covered.
Step 6: Share With the Team
Return the result to the front desk or patient, and write it back to the health system.