3 Ways to Verify Patient Eligibility

Eligibility check, the first step in the insurance claim process involves verifying the eligibility of patients on multiple criteria that includes (but are not limited to) coverage, benefit options, prior authorization, and pre-existing clauses. The process being complex can lead to errors and eventually cause rumbles in the bottom line. Let’s look at some of the ways that can ease your burden and make this job look more amenable.

Phone Call

A phone call is the most fundamental of all the ways. This is accomplished by calling a representative of the insurance. The only difficult part is to gather all the information you need from the call which makes it tedious and error-prone.

Keep these in mind when you initiate a conversation with the insurance:

  1. Before the call, prepare a checklist of items that may be needed during the call. Here are some of those:
    • Patient’s name, date of birth, and demographic details
    • Insurance details including phone number
    • Patient’s policy number and group ID number (if applicable)
  2. Ensure that you are on the call with a representative who represents the insurance on hospital admissions.
  3. You will need to start by providing information about your practice to confirm that the details being shared are HIPAA compliant.
  4. After the handshake steps above, time to get the most out of the conversation. Here are some must-know details that you can ask for a successful eligibility check.
    • Does the patient’s coverage Active? What is the coverage effective from & To Date?
    • What is the patient’s copay, coinsurance?
    • What is the patient’s deductible?
    • If there is a network provider list and limitations of an out-of-network provider?
    • Do you require physician referrals, pre-authorizations, or certificates of medical necessity for reimbursement?

There may be more questions depending on the patient or provider but remember this is the best time to get responses. The provider’s phone line is just like any other customer helpline and so it may make you wait.

Ways to Verify Patient Eligibility

Ways to Verify Patient Eligibility

Online Eligibility Verification:

If contacting over the phone leaves you with Chinese whispers, the web can come to your rescue. Online access for checking eligibility can be done through two ways:

  1. Provider’s online
  2. Automation software with multi payer connection

Any of these can be used and each of these is fast, quick, and affordable. An online service can have tie-ups with many insurance providers and having a single point of access can ease your job a bit as you don’t have to run across different tabs when trying to access information for multiple patients. The information you would gather online should be similar to before. A word of caution if you tread the eligibility path online, sometimes information can be outdated and flawed. So be careful with the data you receive.


Outsourcing could be that magic pill you are looking for. Letting an experienced team handle a load of eligibility checks for patients not only results in a better bottom line but also improves patient satisfaction. One of the examples is policy changes. Insurances are quite frequent with policy changes and that can lead to disruptions if you don’t have enough knowledge of it. Outsourcing can help you get to that level of detail and ease the burden on overall verification. When you choose an outsourcing company, look for the infrastructure and skillsets which should be wide enough to provide you accurate info, with a fast turnaround time. Most professional companies measure and monitor the key metrics, and can help you make significant improvements with respect to denials reduction.

Denials and rejections can be time-consuming and enormous, but the eligibility check step is truly the core step to avoid getting you into trouble with your claim denials.

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