Eligibility Verification: The First Step to Clean Claims

A claim can be coded perfectly and still be denied if the patient’s coverage was not active on the date of service. Eligibility verification is the simplest way to stop these denials before they happen.

What to verify before every visit

• The patient’s plan is active on the date of service.

• The member ID, name and date of birth exactly match the payer’s records.

• Your provider is in network for the patient’s plan.

• Copay, coinsurance and remaining deductible.

• Whether the planned service is covered, and whether it needs a referral or prior authorization.

• Which plan is primary when the patient has more than one.

Verify every visit, not just new patients

Coverage changes more often than most practices expect: new jobs, plan renewals and Medicaid redeterminations all happen during the year. Checking returning patients is just as important as checking new ones.

Use the results at the front desk

Verification is only useful if it changes what happens next. Collect the copay at check-in, tell patients about likely out-of-pocket costs, and stop to resolve coverage problems before the visit, not after the claim is denied.

Conclusion

Eligibility checks take minutes and prevent weeks of rework. Built into scheduling and check-in, they are the foundation of a high clean claim rate.