Verify patient coverage in real-time to avoid claim rejections.
Insurance verification is your first line of defense against claim denials. Verifying coverage before services prevents denied claims, reduces patient complaints about surprise bills, and allows upfront collection of patient responsibility. Our verification team ensures every patient has active, verified coverage before their appointment.
What’s Included:
Real-Time Eligibility Verification:
- Electronic eligibility checks through payer portals and clearinghouses
- Verification performed 24-48 hours before scheduled appointments
- Confirmation of active coverage on date of service
- Patient demographic verification (name, DOB, ID number)
- Subscriber relationship confirmation (self, spouse, dependent)
- Plan type identification (HMO, PPO, POS, EPO)
- Coverage effective dates and termination dates
Coverage Verification:
- Service-specific coverage confirmation
- In-network vs. out-of-network benefit determination
- Covered service limitations and exclusions
- Frequency limitations for specific procedures
- Age-related coverage restrictions
- Pre-existing condition exclusions (if applicable)
- Experimental or investigational service identification
Financial Responsibility Details:
- Individual and family deductible amounts
- Year-to-date deductible met status
- Copayment amounts for office visits, procedures, and specialists
- Coinsurance percentages after deductible
- Out-of-pocket maximum amounts and current status
- Separate deductibles for pharmacy, mental health, etc.
- Patient payment estimates for planned services
Prior Authorization Requirements:
- Identification of services requiring pre-authorization
- Authorization timeframe requirements
- Specific documentation needed for authorization
- Urgent vs. routine authorization pathways
- Notification of missing or pending authorizations
- Alert system for authorization-required services
Referral Verification:
- Confirmation of required specialist referrals
- Referral expiration date tracking
- Number of visits authorized per referral
- PCP (Primary Care Provider) information verification
- Standing referral vs. per-visit referral identification
- Referral renewal notification and coordination
Coordination of Benefits:
- Primary insurance identification and verification
- Secondary insurance coordination
- Tertiary insurance when applicable
- Medicare primary vs. secondary payer determination
- Birthday rule application for dependent coverage
- Subrogation and third-party liability identification
Out-of-Network Benefits:
- Out-of-network deductibles and coinsurance
- Balance billing allowance determination
- UCR (Usual, Customary, and Reasonable) rate information
- Out-of-network claim submission requirements
- Reimbursement method (direct pay vs. patient reimbursement)
Patient Communication:
- Patient notification of financial responsibility before service
- Payment collection strategies for high-deductible plans
- Payment plan options for large balances
- Financial hardship program information
- Clear explanation of insurance benefits and limitations
Documentation & Reporting:
- Verification notes in patient account/chart
- Reference numbers and verification source documentation
- Date, time, and representative name recorded
- Exception reporting for verification issues
- Daily verification status reports for upcoming appointments
- Insurance card scanning and digital storage
Turnaround Time: Same-day verification for scheduled appointments; real-time for walk-ins
Benefits:
- Reduce insurance-related claim denials by 25-30%
- Collect patient responsibility upfront before services
- Eliminate surprise billing and patient complaints
- Improve patient satisfaction with transparent financial communication
- Reduce days in AR by preventing billing delays
- Identify coverage issues before care is provided
- Streamline front desk operations with centralized verification
Integration: Works seamlessly with your scheduling system to trigger automatic verification