Insurance & Eligibility
Live todayABA insurance eligibility verification at the first touch, not the fourth week
Run a real-time 270/271 check the moment a referral reaches the Insurance stage. Coverage, ABA benefit, copay, and prior-auth flag land on the card before anyone asks a family for paperwork.
Coverage active
- Payer
- Blue Cross NC
- Plan
- PPO — Employer
- Effective
- 01/01/2026
- Copay
- $30 / visit
- Deductible met
- $1,120 / $2,000
- ABA benefit
- Covered · prior auth
Authorization path
- Physician verified
- Auth submitted
- Pending
- Authorized
What is TargetFlo Insurance & Eligibility?
TargetFlo Insurance & Eligibility is ABA insurance eligibility verification built into the intake pipeline. It sends real-time 270/271 transactions through a Stedi-compatible connection, maps your payers once, and writes the coverage result to the referral card in the Insurance stage and to the client's Insurance tab in the Client & Family Hub. Authorization progress is tracked as a pipeline stage today; a full authorization management UI is on the roadmap.
How it works
Eligibility in the Insurance stage, in four steps
No payer portal tabs, no callbacks. The check runs where the referral already is.
- 01
Referral reaches Insurance
The card moves from New Intake to the Insurance stage. Payer and member ID were pre-filled from the fax extraction or by front office.
- 02
TargetFlo sends a 270
The eligibility inquiry goes out through a Stedi-compatible connection using your mapped payer ID. No portal logins, no hold music.
- 03
The 271 comes back
Plan, effective dates, copay, deductible, ABA benefit, and prior-authorization flag appear on the card and on the client's Insurance tab.
- 04
Checklist item clears
"Eligibility verified" checks itself off. The coordinator decides: advance to Pending Documents, hold, or close with a reason.
What a 271 surfaces
Seven fields that decide the next four weeks
The response is parsed into plain fields on the referral card and the client record — no reading raw EDI segments.
| Field | What the 271 returns | Why it matters at intake |
|---|---|---|
| Coverage status | Active, inactive, or not found — with the as-of date | Advance or stop before a family gathers documents |
| Plan name & type | e.g. PPO — Employer, Medicaid managed care | Sets expectations for network and referral requirements |
| Effective dates | Plan start and, when present, termination date | Flags coverage that ends before an assessment could finish |
| Copay | Per-visit amount for outpatient behavioral health | Family financial conversation happens at intake, not at session one |
| Deductible | Annual amount and amount met to date | Anticipate out-of-pocket exposure during the assessment period |
| ABA benefit | Whether Applied Behavior Analysis is a covered service | The single most important field for an ABA center |
| Prior-authorization flag | Whether authorization is required before treatment | Starts the Pending Authorization checklist early |
Coverage context
The result lives on the referral, not in someone's inbox
Eligibility is a stage checklist item. When the 271 comes back active with an ABA benefit, the item clears and the coordinator can advance. When it does not, the card stays put with the reason visible to everyone.
- Result written to the referral card and the client's Insurance tab simultaneously
- Stage checklist can require an active result before advancing to Pending Documents
- Dashboard KPI: eligibility-verified rate at the Insurance stage, by location
- Re-check on demand at any later stage; full history on the activity timeline
Payer mapping
“Blue Cross” on the fax. The right payer ID on the wire.
Referral sources write payer names dozens of ways. Payer mapping connects each variation your organization sees to the clearinghouse payer ID once, so front office never has to look up a code.
- Organization-level map from payer names and aliases to payer IDs
- Fax extraction pre-fills the payer field; mapping resolves it before the 270 is sent
- Unmapped payers are flagged, not silently failed
- Medicaid and Medicaid managed care plans mapped separately by state program
Payer map · Southeast ABA Center
- Blue Cross NC · BCBSNC · BCBS of North CarolinaBCBSNCMapped
- NC Medicaid · Medicaid DirectNCMCDMapped
- UnitedHealthcare · UHC · Optum Behavioral87726Mapped
- Aetna Better Health—Needs mapping
Authorization stages
Live todayABA authorization tracking as a pipeline stage
Pending Authorization is the seventh stage of the intake pipeline. Its checklist walks a referral from physician verification to approved units, with a follow-up date at every step.
- 01
Physician verified
Referring physician's order and diagnosis confirmed on the record.
- 02
Auth submitted
Assessment or treatment authorization request sent to the payer; date logged.
- 03
Pending
Follow-up date set; overdue items surface on the dashboard and in tasks.
- 04
Authorized
Approved units and date range recorded; the card can move to Enrolled.
Authorization management UI
Coming soonApproved units per CPT code, date ranges, utilization, and expiry alerts. Built on the same data model so scheduling and claims can draw down against authorized units.
Capabilities
Live today, and what is next
Real-time 270/271 eligibility
Send a 270 inquiry and get the 271 response back in seconds — plan, effective dates, copay, deductible, and ABA benefit.
Payer mapping
Map the payer names your referral sources write on faxes to the payer IDs the clearinghouse expects. Maintained once per organization.
Coverage context at the Insurance stage
The result is written to the referral card and the client's Insurance tab, so the stage checklist can require an active result.
Re-check on demand
Coverage changes. Re-run the check before Diagnostics, before POC, or on the first of the month — history is preserved.
Eligibility history
Every 271 response is stored with timestamp and requester on the client's activity timeline.
Authorization stage tracking
Pending Authorization is a pipeline stage: physician verified → auth submitted → pending → authorized, with a checklist per step.
Authorization management UI
Approved units per CPT code, date ranges, utilization, and expiry alerts — the foundation for scheduling and claims.
Claims submission
Session note → claim with ABA CPT codes 97151–97158 and H0032 on the same data model.
FAQ
Eligibility & authorization FAQs
Related features
Run a live eligibility check in your demo
Book a 30-minute demo. We map your current intake process to the 9-stage pipeline and show how fax, eligibility, tasks, and the parent portal fit together.