Insurance eligibility verification: the front-desk checklist

Eligibility verification answers two questions before a patient is seen: is this person covered, and what will their plan pay for this visit? Get both right and you prevent denials, surprise bills and awkward conversations at checkout.

When to verify

• When the appointment is booked, so there is time to fix problems.
• Again shortly before the visit, because coverage changes, especially at the start of a month or year.
• At check-in, ask whether anything changed: new job, new card, new secondary plan.

The checklist

Patient and plan

• Patient name and date of birth exactly as the plan has them.
• Member ID and group number from the current card (both sides scanned).
• Subscriber name and the patient's relationship to them.
• Plan type (HMO, PPO, EPO, POS, Medicare Advantage, Medicaid managed care).

Coverage

• Coverage is active on the date of service.
• Your provider is in network for this plan (not just this payer).
• The service is covered under the plan's benefits.
• Whether a referral from the primary care provider is required.
• Whether prior authorization is required for the planned service.

Patient cost

• Copay for this visit type.
• Deductible: the total and how much has been met.
• Coinsurance percentage after the deductible.
• Out-of-pocket maximum and how much has been met.
• Visit limits for therapy, chiropractic or behavioral health, and how many are used.

Other coverage

• Any secondary insurance, and which plan is primary.
• Whether behavioral health, therapy or imaging is managed by a separate company.

Electronic checks and their limits

An electronic eligibility request (the X12 270 transaction) returns a response (the 271) with coverage status and often benefit details. It is fast and should be the default. But responses are sometimes incomplete, especially for specialty benefits, visit limits and carve-outs. When the response does not answer your question, call the payer or use their portal, and write down who you spoke to, when, and the reference number.

What to do when something is wrong

• Inactive coverage: contact the patient before the visit. They may have a new plan.
• Out of network: tell the patient before the visit, with an estimate.
• Authorization needed: request it now, or reschedule until it is approved.
• High deductible: give the patient an estimate and collect at the visit.

Make it routine

Eligibility only prevents denials when it happens every time. That means a daily worklist of upcoming appointments, re-checks close to the visit, and alerts for anything that needs action. GetMax runs real-time eligibility on every scheduled patient and flags problems to the front desk; our eligibility verification service can handle the phone calls too.