Insurance eligibility verification services
Insurance eligibility verification is checking, before a visit, that a patient’s coverage is active and what their plan covers for the service, so the claim does not fail on eligibility.
Before the visit
What gets checkedA verification answers two questions. Pick a part to see what goes wrong without it.
If it isn’t checked
Coverage that changed
The patient changed plans, lost coverage or moved to Medicare since their last visit, and the claim goes to a payer that no longer covers them.
Eligibility or benefits? A visit needs both checked.
Active coverage doesn’t mean the plan pays for this service. A verification answers two questions.
Eligibility
Is the patient covered on the date of service? The plan is active, the member ID and subscriber details are right, and the plan on file is the one that will be billed.
Benefits
What does the plan pay for this service? The copay, the deductible left to meet, coinsurance, visit limits, network status, and any referral or authorization the plan requires.
What goes wrong when coverage isn’t checked?
Coverage that changed
The patient changed plans, lost coverage or moved to Medicare since their last visit, and the claim goes to a payer that no longer covers them.
Details that don’t match
A wrong member ID, a misspelled name or the wrong subscriber, and the payer can’t match the claim to a patient.
Services the plan doesn’t pay for
Visit limits already used, a service the plan excludes, or a referral or authorization the plan requires and the claim can’t show.
Out-of-network surprises
A provider who isn’t in the patient’s network, found only when the claim comes back.
Balances nobody mentioned
A deductible or coinsurance found after the visit, when the patient is billed for something nobody told them about.
How does insurance eligibility verification work?
Start from your schedule
We work from the visits on your schedule and the insurance details on file, primary and secondary plans included.
Confirm coverage for the date of service
Each patient’s coverage is checked with the payer, through its portal or an electronic eligibility check, for the day of the visit.
Check the benefits for the service
We confirm what the plan pays for the visit: copay, deductible, coinsurance, visit limits and network status.
Flag what needs action
Anything that would stop the claim, such as inactive coverage, the wrong payer on file, or a referral or authorization the plan requires, is flagged to your team before the visit.
Record it where your team works
What we find goes into your practice management system, so the front desk knows what to collect and the claim goes to the right payer.
Related billing services
- Claims submissionCharges entered, scrubbed and submitted clean, then tracked to a decision.
- Denial managementEvery denial traced to its cause, corrected or appealed, and stopped from repeating.
- Payment postingERAs and EOBs posted accurately, with underpayments flagged.
- Credentialing & enrollmentProviders credentialed and enrolled with the payers you need, and kept current.
Related specialties
Eligibility verification questions
What is insurance eligibility verification?
Why check eligibility before every visit, not just the first?
What happens when coverage can’t be confirmed?
Find out how many of your claims fail on eligibility.
Unsure how much revenue you are missing? Start with a complimentary billing audit.
Free consultation