You check the insurance company's website, or a rep tells you the patient is active. Stratus says inactive. This is one of the most common things offices report to us, and when the two disagree we want to hear about it — not so we can tell you to try again, but because it usually points at something we need to fix.
Why the two can disagree
A breakdown isn't a copy of the insurance company's website. It's an answer we get from that company, and there's more than one way to ask.
We asked electronically, you looked at the website. Most insurance companies run two systems: the electronic feed they answer benefit requests on, and the provider website your office logs into. Those two are supposed to agree. In practice they disagree more often than anyone would like, and the electronic feed is sometimes the one that's stale.
What you're reading may be an older check. Every check we run asks the insurance company fresh — we never hand back a stored answer. What can happen is that an automatic check gets skipped: if the same patient and the same insurance record were already checked within the past month, our automatic sweep won't run another one. So the status on your screen can be a few weeks old, and coverage may have changed since. Always check the renewal date listed on the breakdown too — if the plan has renewed since the check ran, the answer you're looking at is from the old plan year. A check you request yourself always runs fresh, so if the status looks wrong or the plan has rolled over, request one.
Coverage hasn't started yet. We ask whether the patient is covered right now, not on their appointment date. Someone enrolled with a start date two weeks out is genuinely not active today, while the rep looking at the same record sees the enrollment and says yes.
Coverage ended, backdated. Terminations are often entered after the fact with an earlier effective date. Both answers were true when they were given.
The patient has more than one policy with the same company. This is a big one. Someone changed jobs, or is covered under two plans, and the old employer's policy is still sitting on their record as terminated. We read one policy, the rep read the other. Sometimes the company's own website hides ended policies from search results, which pushes our lookup onto a different plan entirely.
Medical and dental are bundled. A few companies only report dental status when the medical side is also active. If the rep was reading medical and we were reading dental — or the reverse — you get two confident, opposite answers.
The company is administering for someone else. The card says one name, but the coverage actually sits with another company underneath. We can find "no active coverage here" and be technically right while the patient has perfectly good benefits.
We reached the insurance company's website but couldn't read a clear answer. With a small number of companies, a page that times out or comes back half-loaded can still be accepted as an answer. That usually shows up as 0% on every procedure code rather than as an inactive status, and occasionally as a coverage status we shouldn't have concluded at all. Either way it's a bug on our side, and it's exactly the kind of thing your report lets us catch.
How to tell a mismatch from a real inactive
A wrong member ID, a wrong date of birth, or a patient the insurance company can't find normally comes back as Action Required, with a note about what didn't match. Inactive means we found the person and the insurance company reported their coverage as inactive.
Two exceptions are worth knowing. On a basic eligibility check, a date of birth that doesn't match shows as Unavailable. And with a few insurance companies, a patient search that returns nothing can be recorded as Inactive. If Inactive looks wrong to you, report it either way — we'd rather look.
The eligibility badge on your schedule can also be older than the newest breakdown, and anything from a previous year is labelled Stale.
What to do
1. Flag the field on the breakdown. Open the breakdown and click the eligibility status value — it opens a Report Inaccuracy window. Enter what the status should be and add a short note. Report one field per submission. This is the fastest route into our queue, and it tells us exactly which value was wrong.
2. Then message support. The flag gets it looked at; the message is what lets us find the cause. Please include:
Patient name and the date the breakdown was requested
The insurance company, and the plan or group name if you have it
What you were told and where — the company's website, or a rep's name and reference number
When you checked. The date and roughly the time. This matters more than people expect, because it tells us whether we were looking at an older answer
Whether it was a basic or a full breakdown
What happens next
These go to our team to investigate, not into a "try it again" pile. Most come down to how we read one specific insurance company, and the fix is a change on our side that helps every office using that company. That's why we ask for specifics instead of telling you to resubmit.
If you need something in hand today, request the breakdown again — a check you request yourself always goes back to the insurance company rather than repeating an earlier answer. If a full breakdown came back wrong, say so when you report it and ask us about a credit.