Eligibility: What Is It, Anyway?

April 2024


To be sure that your practice is paid for services rendered, you want to verify every patient’s eligibility for medical coverage.

Why? Because the turnaround time for paid claims is reduced greatly when coverage has been verified prior to services, which improves cash flow. Plus, after treatment is rendered, most practices recover only approximately 30 percent of patient balances. That’s 70 percent the practice will never see! If the patient’s coverage is verified prior to treatment, the practice could collect 100 percent of the patient balance prior to treatment.

What You’ll Need to Get Started

To verify coverage, you will need the patient’s:

  • Name and demographics
  • Date of birth
  • PRIMARY insurance company
  • Policy number
  • Group number

You will also need the policy owner’s name and date of birth, and the patient’s relationship to the policy owner.

Obtain the date the policy started, as well as any end date. Be sure to verify coverage for your specific date of service.

Don’t Forget Secondary Coverage

One step that many practices miss is asking for and verifying any secondary coverage. This is just as important as verifying primary coverage! Some patients with secondary insurance don’t understand how two insurances work; so, they give you the insurance they want to use (which may not be the correct one).

Note that Medicaid is always the payer of last resort! If a patient presents with a commercial payer and a Medicaid payer, the Medicaid is secondary (regardless of how the patient wishes the claim to be processed). If the patient does not wish to send the claim to their primary insurer—for whatever reason—you can’t send the claim to Medicaid. The patient must pay cash.

If a husband and wife each have coverage for themselves and each other, the policy the individual owns is primary and the policy owned by the spouse is secondary. For instance, the husband has UHC and his wife has BCBS. She uses her BCBS as primary and his UHC as secondary. He uses UHC primary and BCBS secondary.

The “Birthday Rule”

If parents have dual coverage on their children, the parent with the birthday earliest in the calendar year is primary. For example, Mom has BCBS and is born in June, while Dad has UHC and born in November; Mom’s BCBS is primary for the children. The year of birth doesn’t factor in—only the day and month of birth. The National Association of Insurance Commissioners states, “If the parents have the exact same date of birth; the oldest policy is primary.” Be sure to check your specific payer rules for specific guidelines and coverage, as well as COBRA coverage and coverage for divorced parents.

Benefits Matter as much as Coverage

In addition to verifying coverage, you need to also verify the patient’s benefits and how they relate to your practice and the treatment the patient is receiving. For example, are you a specialty? Is there a limit to benefits received or the number of visits? Some insurances limit the number of visits a patient can have for Chiropractic services each year, for instance.

Or maybe the plan has a dollar limit. For example, some plans have a lifetime maximum of IVF treatment. If you are an IVF specialist, this is important.

How are Mental/behavioral health claims processed? Is there a separate address, EDI number? Are these benefits handled differently? You need to ascertain what services are covered and how the claims are processed as they relate to your specific practice and the services provided.

Also important to note, if you provide services in a location other than your practice, how does that impact the patient’s benefits and the claim processing? Do benefits differ based on the place of service?

Patient Responsibility

You also need to determine what, if any, costs will fall to the patient.

For example, does the patient have a deductible? If so, is the deductible met? How much is remaining? Will any services provided be applied to the patient’s deductible? How is the deductible calculated? On a calendar year or on a plan year? If it’s the plan year, you will also need to obtain the start and end date of the plan.

Will the patient be responsible for any co-insurance amounts today?

Is there a Co-pay amount? How much? Are you contracted as a specialist, thereby requiring a higher co-pay amount or a PCP?

These questions are important to answer, so that the patient will be informed of their financial responsibility before receiving treatment—and so that the right amount can be collected from the patient at time of service. This reduces the aging of accounts and increases practice cash flow!

Now that You Know the Why, Here’s How

Verifying eligibility can be done a couple different ways

1) Electronically, one can either go through the payer’s secure portal on their website, or through the practice clearinghouse PMS. Either way, the electronic report should be printed with the date and time documented so if eligibility for that specific date ever comes into question, there is a paper trail supporting the transaction. You should also verify the EDI number for the plan.

2) Verify by phone. When verifying by phone, call each payer to verify eligibility and benefits. Be sure to document the date and time of the call, as well as the representative’s name. It’s also a good idea to verify the phone number and address for this particular plan, as well as the EDI number. You want to be sure you are submitting the claim to the correct place, the first time.

Phone is usually the best when verifying specific benefits and how they relate to a specific procedure, (i.e.: IVF treatment or a surgery)

Once Isn’t Enough

On an annual basis, the practice should update each patient’s demographics as well as verify eligibility and benefits.

At each subsequent visit, eligibility should be verified, and benefits related to this visit.

Take the above steps to ensure that your practice has the best chance of getting its claims paid the first time!


Contact Info

Advanced Coding Services
Email: beth@advancedcodingservices.com
Website advancedcodingservices.com

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