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.
- Insurance eligibility verification
- Benefits verification for the scheduled service
- Active coverage validation
- Policy information verification
- Member ID validation
- Effective and termination date verification
- Copay information
- Deductible status and remaining amount
- Coinsurance verification
- Out-of-pocket maximum position where the payer publishes it
- Prior-authorization requirement identification
- Referral requirement identification
- Secondary and tertiary insurance verification
- Coordination of benefits order
- Plan and network status for the rendering provider
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.
- 01Pull schedule
- 02Check payer
- 03Validate plan
- 04Flag gaps
- 05Record
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.