Eligibility & benefits verification
Insurance Eligibility Verification, Done Before the Visit
An eligibility check that happens after the claim is rejected is not an eligibility check, it is a post-mortem. We verify coverage, benefits and authorization requirements against the payer ahead of the date of service, and we record what we found, so the answer is in the account when somebody needs it rather than in somebody's memory.
What we verify
Against the payer, not against what is already sitting in the record. A stale eligibility response is worse than none, because it is trusted.
Request an RCM AssessmentInsurance eligibility verification
Coverage is confirmed with the payer for the specific date of service, through your portals and eligibility tools, rather than read back from whatever is already sitting in the patient record.
Benefits verification for the scheduled service
Benefits are checked for the service actually scheduled, not for the plan in general. A patient can be covered and still have no benefit for the procedure on the calendar.
Active coverage validation
Whether the policy is live on the date of service, which is a different question from whether it was live on the day the appointment was booked.
Policy information verification
Payer, plan, policy and group numbers are confirmed against the payer's own response rather than against the card, which may be out of date by the time it is presented.
Member ID validation
The member identifier is validated with the payer, because a transposed digit produces a rejection that looks like a coverage problem and is not one.
Effective and termination date verification
Effective and termination dates are recorded, so a policy that ends between booking and visit is caught before the service rather than after the claim.
Copay information
The copay that applies to the scheduled service, captured so your front desk can collect the right amount at the right time instead of billing for it afterwards.
Deductible status and remaining amount
How much of the deductible is met and how much remains at the time of checking, with the date of the check recorded, because the position moves as the patient's other claims adjudicate.
Coinsurance verification
The coinsurance share that applies once the deductible is satisfied, so any patient-responsibility estimate is built from the plan rather than from an assumption.
Out-of-pocket maximum position where the payer publishes it
Where the payer publishes it, the out-of-pocket position is captured too. Where the payer does not, it is recorded as unavailable rather than left blank for somebody to read as zero.
Prior-authorization requirement identification
Whether the scheduled service requires prior authorization under the patient's plan, identified and flagged to your team ahead of the visit. Obtaining and submitting the authorization stays with your staff.
Referral requirement identification
Whether the plan requires a referral on file for the rendering provider, flagged in the same pass, because a missing referral denies as cleanly as a missing authorization.
Secondary and tertiary insurance verification
Additional coverage is verified rather than assumed absent. A secondary policy nobody checked for becomes a patient balance that should never have existed.
Coordination of benefits order
Which policy pays first is confirmed, because billing them in the wrong order produces a denial that reads like a coverage problem and is really a sequencing one.
Plan and network status for the rendering provider
Whether the rendering provider is in network under that specific plan, not merely contracted with that payer — the distinction that turns a covered service into a patient balance.
Your queues, your system, the same people on them every day.
How a verification runs
Worked from your schedule, far enough ahead that a problem is still fixable.
Pull schedule
The upcoming appointment schedule is taken from your system on the cadence you set, far enough ahead that a coverage problem is still something your front desk can do something about.
Check payer
Coverage is checked with the payer through your portals and eligibility tools, for the specific date of service, rather than read back from whatever is already sitting in the patient record.
Validate plan
Plan and network status for the rendering provider, effective and termination dates, and the copay, deductible and coinsurance position are confirmed against the payer's response.
Flag gaps
Inactive coverage, a plan that does not cover the scheduled service, a missing referral or a prior-authorization requirement are flagged to your team before the visit rather than after the claim.
Record
The response is written to the account with the date it was obtained and the source it came from, so the next person to open it can see what was checked instead of checking it again.
What you get
- Verification recorded in the account, not in a spreadsheet
- Findings go into your practice management system in your format, so the front desk and the biller see the same answer.
- An exception list you can act on before the visit
- Terminated coverage, missing authorization, wrong plan, unmet deductible. Raised with the reason, in time to do something about it.
- Prior-authorization requirements identified, not obtained
- We tell you an authorization is required and what the payer asks for. Obtaining it stays with the clinical team, where the documentation lives.
- A consistent record format
- Same fields, same place, every time, so the next person down the line does not have to interpret it.
Reporting cadence
- Daily
- Verifications completed against the schedule, and the exception list.
- Weekly
- Patterns worth acting on, such as a payer changing what it requires.
- Monthly
- Accuracy and turnaround against the agreed measures.
How it is measured
KPIs and SLAs are customized according to the client's process requirements and contractual scope.
These are the measures we report on. The targets against them belong in your agreement, where they can be negotiated and enforced, rather than on a web page where they cannot.
- Eligibility verification turnaround time
- Verification accuracy, sampled at transaction level
- Coverage of the scheduled book
- Exceptions raised before the date of service
- First-pass quality
- Process compliance against the SOP
- SLA compliance
Stop paying for denials you already knew about
Send us a week of your schedule volume and your payer mix, and we will come back with a verification model, a team size and a transition plan.