Eligibility verification is checking, before a patient is seen, that their insurance coverage is active on the date of service and what the plan pays for: copays, deductibles, coinsurance, visit limits and whether referrals or authorizations are required.
It is usually done electronically with an X12 270/271 transaction, with phone or portal follow-up when the electronic response is incomplete. Skipped or outdated checks are a leading cause of preventable denials.
Related terms
- 270/271 transaction
- The standard electronic request (270) and response (271) for insurance eligibility.
- Prior authorization
- A payer's approval, obtained before a service, that it will consider paying for it.
- Coordination of benefits (COB)
- The rules that decide which plan pays first when a patient has more than one.