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Real-Time Eligibility
Overview

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.Background .
.Real-Time Eligibility Transaction.
.Transaction Outcomes .
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Background
The electronic eligibility transaction was developed to enable dentists to request member eligibility status via electronic data interchange (EDI). Some highlights of the electronic eligibility transaction are:

  • Available for ALL Aetna dental benefit plans, including DMO, PPO and Indemnity Plans
  • Available 24 hours per day, seven days per week
  • Primary care and specialty dentists will have the capability to complete an eligibility transaction.

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Real-Time Eligibility Transaction
The real-time eligibility benefit inquiry may be used for any Aetna Dental product (list includes Indemnity and PPO, DMO, Aetna Advantage Plus, Aetna Advantage Dental, Basic Dental, Family Preventive, Discount Dental and Pediatric Direct Access). The inquiry will be based on the member’s information and an American Dental Association (ADA) CDT-2005 procedure code. Inquiries can also be made on the above products with an “Aetna HealthFund”.

The eligibility transaction requires the Employee’s Social Security number or member ID and patient date of birth to perform an eligibility search. For members with an HMO rider product, only the member ID is required.

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Transaction Outcomes
1. Error Response
When a real-time benefit eligibility transaction is unsuccessful, the provider will receive an error text message.

2. Patient and Plan Benefit Response
Below is a complete list of information that can be returned:

  • Payer Information – name and ID
  • Requesting provider name and number with associated information
  • Subscriber/patient information:
         SSN or member ID
         Group name/number and/or plan name/plan number
         Insurer name, address
         Date of birth
         Gender
         Facility name and address (claim office)
         Plan begin date
         Service date (date inquiry is made)
  • Procedure code
  • Active coverage
  • Coverage level
  • Insurance type
  • Detailed financials, as applicable:
         Co-pay
         Deductible
         Coinsurance
         Exclusions
         Limitations
         Amount remaining

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