Eligibility verification in depth: what to check and when
Eligibility verification confirms that a patient’s coverage is active and shows what the plan will pay before the visit. It is the cheapest point in the revenue cycle to prevent a denial.
What to verify
- Coverage effective and termination dates and plan type, including Medicare Advantage versus Original Medicare
- Copay, coinsurance, deductible and out-of-pocket status
- In-network or out-of-network status for the provider and facility
- Referral and prior authorization requirements for the planned service
- Coordination of benefits, including primary, secondary and Medicare Secondary Payer information
How and when to verify
Most practices use the HIPAA 270/271 electronic transaction or the payer portal. Verifying at scheduling and again shortly before the visit catches coverage changes. Front desk teams should also collect an updated insurance card and photo ID at every visit.
Related denial codes
| CARC | Meaning | Prevention |
|---|---|---|
| 27 | Expenses incurred after coverage terminated | Re-verify before the date of service |
| 31 | Patient cannot be identified as the insured | Match name, date of birth and subscriber ID to the card |
| 22 | May be covered by another payer per coordination of benefits | Confirm primary and secondary payers |
| 109 | Claim not covered by this payer | Confirm plan and payer before billing |
Verification workflow
- Collect insurance details at scheduling.
- Send the 270 inquiry or check the portal and record the benefits returned.
- Flag services that need authorization or referrals.
- Re-verify before the visit and update the patient account.
- Explain expected patient responsibility before service.