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Pharmacy Benefits Eligibility Checking

There are Surescripts Pharmacy Benefits requirements for finding a patient match. The Surecripts patient match for Pharmacy Benefits also applies for Medication History since eligibility response information is sent in the medication history request for a particular patient. 

There are five key fields that are recommended by Surescripts:

  • First Name
  • Last Name
  • Date of Birth
  • Gender
  • Zip Code

Message Responses in OP

  • Insufficient Information: When insufficient identifying information is sent to Surescripts to uniquely identify a patient the following message is returned "Subscriber/Insured Not Found" or "Patient Not Found". If appropriate will also send recommendations for future searches.
  • Multiple Matches: When there are multiple matches found the following message is returned "Subscriber/Insured Not Found" or "Patient Not Found". If possible you will receive a list of the missing data needed to help identify an exact patient match.
  • Demographic Discrepancy: When a patient match is found, but there is a discrepancy with the information found in OP, a conflict flag is shown in OP on the Pharmacy Benefits tab and a warning displayed.

Note: Currently there is no method to reconcile or accept demographics from Surescripts.