There are two steps to medical eligibility verification: patient eligibility verification and provider plan participation. Both verifications are necessary to ensure proper claim processing and reimbursement.
The process of determining patient insurance eligibility includes verifying the patient’s insurance coverage, all covered benefits, deductible, co-insurance, and co-payment requirements. This step confirms not only what the carrier will cover but, critically, the patient’s responsibility (what the practice must bill directly to the patient).
There is no clear-cut method for verifying medical insurance eligibility among the various insurance carriers, and each patient case must be processed individually. Depending on the carrier, eligibility may be verified by web portal or phone.
It is also important to remember that a patient’s insurance eligibility can change from month to month and that the verification process must be done at each visit. For instance, while a patient may have confirmed Medicare eligibility in the month of December, the same patient can switch to a Medicare Advantage plan in January and have a completely different set of benefits. Continuous eligibility verification will ensure fewer denials, faster payment, and a better overall patient experience with your practice.
Similarly, the process of determining a provider’s plan participation is also required. Carriers like 1199, Aetna, Cigna, Empire Blue Cross Blue Shield, Healthfirst, Metroplus, and United Healthcare have multiple sub-plans that may not be covered under a general provider enrollment contract. For this reason, each plan must be contacted separately to confirm a provider’s participation status.
The Pier 17 Authorizations Department offers efficient eligibility and provider participation verification services that check insurance eligibility, payable benefits, co-pays, deductibles, termination dates, and more. Our experienced team will ensure that only covered patients are seen by the practice and improve your overall billing cycle revenue. Contact us today!
cardiology prior authorization credentialing insurance eligibility medical eligibility verification medical necessity medical record patient’s insurance eligibility post-authorization pre-authorization pre authorization approval precertification prior authorization prior authorization requirements retroactive authorizations
