Insurance Eligibility Verification: The First Step to Clean Claims

A claim can be coded perfectly and still be denied because the patient's coverage was not active or the wrong payer was billed. Eligibility and benefits verification before each visit is the simplest way to prevent these denials.

When to verify

• Before every new patient visit
• Before every follow-up visit – coverage can change at any time
• At the start of each year and whenever a patient reports a new plan

What to verify

• Active coverage on the date of service and the correct member ID
• Primary, secondary and coordination of benefits
• Plan type and whether your provider is in network
• Copay, coinsurance, deductible and how much of the deductible is met
• Referral and prior authorization requirements for planned services
• Visit limits for therapy and other limited benefits

How verification is done

Most checks are done electronically through the clearinghouse or payer portal using the standard 270/271 eligibility transaction. Some details – such as visit limits or authorization rules – still require a payer portal lookup or a call.

Benefits for the practice and the patient

• Fewer eligibility denials and less rework
• Accurate patient estimates and better collections at check-in
• No surprise bills for patients
• Correct payer order for secondary claims