Insurance Eligibility Verification Steps

01 December 2021
insurance eligibility verification steps

How To Verify Insurance Eligibility & Benefits?

In the medical claims, insurance coverage related reasons are among the top reasons for claim denials. A large number of claims gets denied or delayed for insurance related details like insurance was not active during the procedure period, the particular medical service or procedure was not covered by the insurance plan, etc. A strong, effective insurance eligibility verification process can arrest these challenges, reduce denials, and improve the overall revenue cycle.

We should ensure that the insurance details are verified thoroughly before the medical services are initiated so that there is no confusion or challenged after the treatment is provided. Any hiccup can be identified and sorted out at the initial stages.

Denial Reasons - Ineffective Insurance eligibility verification

• Policy not active – expired or terminated
• Co-ordination of benefits not updated
• Service is not covered
• Benefits exhausted or plan limit reached
• Not obtaining preauthorization or referral
• Incorrect or incomplete patient information
• Incorrect or incomplete policy details
• Any typo errors
• Missed mandatory information

There could be other possible scenarios also. To avoid denials arising primarily out of insurance eligibility checks, a detailed verification process is mandatory.

The following steps will strengthen the entire verification process and reduce denials.

1. Collect a copy of the insurance card of the patient
Initiate the verification process by collecting the insurance card of the patient to file in records and for further process. This becomes the primary document for the verification. Even if the patient has submitted a copy during the earlier services, collecting a copy again would help us check for any changes or even to check the basic expiry.

2. Insurance eligibility verification checklist
Once the copy is collected, all the information in the below checklist should be captured and recorded in the patient’s records. Any mismatch would end up in medical bill denial.

• Patient name, contact details

• Primary Insured person’s name (If the primary insured person is different from the patient)

• Insurance provider’s name, contact details and address

• Insurance number and Group ID number

• Whether the medical practice centre and the physician is enrolled with the insurance provider

• Policy period (Start and end date of the policy)

• Policy coverage amount and amount used so far

• Policy service coverage details (Medical Services included in the coverage)

• Co-pay and deductible details

Pre-authorization details for specific procedures, treatments and medical services

• Any other specific requirements of the plan for claims and limitations

3. Get in touch with the Insurance Provider
After collecting all the details, it is a good practice to call up the insurance provider and verify all the policy details from them and confirm all details. Any mismatch can be easily identified at this stage and corrected. With electronic download option available now, all data can be downloaded easily which makes the process faster and easier.

4. Collect and record complete and correct information
Ensure the team collects all relevant information required with regards to the insurance from the patient and from the insurance provider. The team should also be doubly careful while recording all the information of the patient and their claims. Any small error can also lead to denial and will delay the claim process. This step forms the base for the entire claim process and the staff and team handling should be vigilant.

5. Connect to the patient when necessary
There could be clarifications, questions, concerns arising in the collection, recording and verification process. The staff should not hesitate to connect to the patient and clarify the doubts. A through follow-up communication system with the patient through phone calls and mail is very essential. Any information like co-pays, deductibles, coverage shortage etc. should be notified immediately to the patient so that those amounts shall be collected from the patient within shorter span of time.