This article explains how pharmacy teams check a patient's insurance eligibility in MedMe and read the results. It covers running an eligibility check, interpreting coverage status and benefits, deciding whether to collect patient payment details, and what to do when a check does not return the expected result.
Table of Contents
Overview
An eligibility check asks the payer whether a patient's insurance is active and what it covers. Running it before the appointment or before creating a claim helps pharmacy teams catch the wrong payer or inactive coverage early, and gives an idea of what the patient may owe.
Key terms:
Insurance eligibility — confirms that the patient's insurance is active and can be used for a claim.
Insurance discovery — finds other coverage the patient may have, such as a primary or secondary payer that is not on the card provided.
Please Note: MedMe currently supports insurance eligibility only. Insurance discovery is not yet available.
Before Checking Eligibility
Eligibility can only be checked for an insurance that is:
Added to the patient profile, either by the patient during online intake or by pharmacy staff.
Set to Active. Inactive insurances cannot be verified.
Billed to the correct payer. The patient's medical insurance, not a drug plan, with the actual insurer selected.
To add an insurance or choose the right payer, see How to Add and Manage a Patient's Insurance in MedMe.
Step 1: Run an Eligibility Check
Open the Patient Profile and locate the Insurance card on the Overview tab.
On the insurance row, select the verify button (Verify eligibility).
In the Verify Insurance modal, confirm the Date of Service. It defaults to today; shortcuts for 1 week ago and 1 month ago are available. The date must be within the last 24 months or the next 4 months.
Select Verify.
MedMe sends the request to the payer and opens the Insurance Details modal with two tabs: Subscriber Info and Service Types. The insurance row then shows the Verification Request Date, so the team can see when coverage was last checked.
Step 2: Read the Results
Subscriber Info shows the subscriber and plan details the payer returned. Compare them with the card; a mismatch in name, date of birth, or member ID is a sign the insurance was entered incorrectly.
Service Types is where most of the information is. Focus on the following:
Coverage status
Active — the coverage is active.
Inactive — the insurance exists, but the coverage is not active.
Entered-in-error — the insurance details were entered incorrectly and need to be reviewed.
Warning: An entered-in-error status usually means the member ID, the payer, or the subscriber's demographic details are wrong. Edit the insurance, correct the details, and check eligibility again.
Benefits
Deductibles
Co-pay amounts
Co-insurance
Network status
Please Note: MedMe shows everything the payer returns. Some payers do not return full benefit details, so a deductible, co-pay, or network status can still apply even when no value is shown. The final amount is confirmed when the claim is processed.
Warning and Error pills
When the payer returns an issue, a Warning or Error pill appears on the insurance row. Hover over it to see the error code, the recommended action, and a possible resolution.
Step 3: Decide Whether to Collect Patient Payment Details
Collecting the patient's payment details protects the pharmacy if a claim is denied or the patient owes a remaining deductible, co-pay, or co-insurance. It is not always practical, so use the eligibility results to decide:
A deductible or co-insurance is shown. Collecting payment details may be appropriate.
The patient has Medicaid. Medicaid patients rarely have a co-pay, and it is often waived.
The pharmacy's network status with the payer. In-network claims are more likely to be paid. Out-of-network claims may be allowed but are less reliable.
Warning: If the patient is likely to pay out of pocket, and subject to state requirements, the pharmacy should get the patient's explicit consent before collecting payment. Payment should only be collected through a secure, PCI-compliant system, which may include the pharmacy management system. MedMe does not store credit card information.
Once eligibility is confirmed and payment has been considered, complete the appointment and create the claim. See How to Create and Submit a Claim in MedMe.
Troubleshooting
The check returns no response, or says the provider is not on file. Some payers only return eligibility to providers that are enrolled or in-network with them, so the patient may still be covered. The pharmacy's eligibility enrolment with that payer may not be complete; contact the MedMe RCM team. See Medical Billing 101: What to Know Before Submitting Claims in MedMe.
The result is Entered-in-error or the member is not found. Check the member ID, the payer, and the subscriber's name, date of birth, and relationship to the patient against the card.
The coverage shows as Inactive. Ask the patient whether their insurance has changed. If it has, add the new insurance and mark the old one Inactive.
The verify button is disabled. Only Active insurances can be verified. Edit the insurance and set the status to Active.
Conclusion
Checking insurance eligibility in MedMe confirms that a patient's coverage is active, shows what the patient may owe, and catches payer or member ID mistakes before a claim is submitted. Running the check and reading the results helps pharmacy teams submit claims with confidence.
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Have Questions?
Email care@medmehealth.com or message us via live chat for further assistance.