🛡️ Insurance Verification – Quick Reference Guide

Eligibility Check Protocol:

• Check insurance eligibility for all patients.

• If eligibility has already been verified within the last 29 calendar days, no further action is needed.

• If 30 days or more have passed since the last check, run a new eligibility verification.

Entering Insurance in Athena

• Carefully enter insurance details into the patient's chart.

• Use the plan with the matching address and payer ID (found on the card).

• If the card isn’t available, ask for the claims address over the phone and search in Athena using that address (leave off "P.O." if using a P.O. Box).

Important Things to Check

• Make sure the patient’s insurance eligibility has been checked within the past week. If it hasn’t, click 'Perform Eligibility Check' to run it now.

• Dependent Info: Check who the policyholder is (see last two digits of the Pres ID number):

  • 00 = Primary (guarantor)

  • 01 = Spouse or first dependent

  • 02, 03, etc. = Other dependents

• Plan Type: Make sure you're selecting the correct type (HMO, PPO, Medicaid, etc.).

• Effective Dates: Use the oldest date with no break in coverage, especially for Presbyterian plans.

• Expiration Dates: NEVER ENTER EXPIRAITON DATES

• Correct Entry Impacts Pay: For example, choosing a commercial plan instead of Medicaid can lead to denied or underpaid claims.

Quick Tips for Presbyterian Insurance

• Use the Presbyterian Portal: https://sso2.phs.org

• Search by name and DOB, not ID – it shows all active plans.

• Check for Medicare Advantage (Part C) or Medicaid MCOs under Presbyterian.

• Effective dates matter – check carefully and enter the correct one.

NM Medicaid Tips

• Look for the Managed Care Organization (MCO):

  • BCBS, Presbyterian, Western Sky (→ Replaced by Molina in 2024)

• If no MCO is listed → it’s Straight NM Medicaid.

• Use the Medicaid Portal: https://nmmedicaid.portal.conduent.com

Remember

• please run an eligibility check on all patients insurance information; if it has been ran in less than <29 calendar days- you can skip- if you see a patients eligibility on insurance has not been ran within 30days, please perform an eligilit

• Details matter: Even a small mistake (wrong ID, missing letters) can delay billing.

• Insurance selection affects how much we get paid.

• If in doubt, reach out to the Billing Team (ext 2289)  for help.

• Have patient's submit a picture through patient portal if needed

• Confirm if they have secondary or tertiary insurance and make sure they upload those cards too.

Southwest Care Center Organization Info For Portals: 

• NPI: 1871602698

• Tax ID: 85-0397444

• Medicaid Provider ID: 000K5766

Portal Links: