Eligibility verification

The electronic check is the X12 270 inquiry and 271 response. You send the patient’s identifiers and the date of service; the payer returns coverage status, plan name and group, the member’s cost sharing, including the copay, how much of the deductible has been met, coinsurance and the out-of-pocket position, other payers on file, and often the primary care provider and referral information. Payer portals return the same data by hand, and a phone call is the fallback for anything the 271 does not carry, such as whether a specific service needs authorization under that plan.

Eligibility denials are the most avoidable kind: coverage terminated, patient not found, wrong payer, service not covered under the plan. Each one is a claim that will never pay as filed and a patient who was not told what they owed. Verifying before the visit sets up the copay collection and the authorization request. Verifying for the actual date of service matters because coverage changes at month ends and with job changes, and a check done at scheduling can be stale by the time the patient arrives.

The mistake is reading only the active flag. Check the payer ID and plan, because a patient can be active in a different product than the one on file; read the other-coverage segment for COB; and look at the benefit lines for the service planned, not the plan in general. Keep the 271 response on the account as evidence of what the payer said that day.