Verify patient eligibility before a visit

For: RCM Specialist (or front-desk staff at practice) · Time: 1–3 min per check · Frequency: Before every visit (ideal); pre-DOS for new patients (mandatory)

Trigger

New patient scheduled, returning patient with insurance change, or you suspect coverage has lapsed. Or you're working a denial that suggests eligibility was the problem.

Outcome

You know definitively: was this patient covered by this plan on this date of service, what's their copay/deductible/coinsurance, is there a need for prior auth on the planned service. Result captured in the eligibility log for audit.

Where

• RCM → Eligibility tab
• Patient Detail — recent eligibility checks per patient

Steps

1. RCM → Eligibility → New Check.
2. Pick the patient. Search by name + DOB. If new patient, you'll need to enter:
   • Full name, DOB, gender
   • Member ID (from their insurance card)
   • Payer name (autocomplete from the payers catalog)
3. Pick the provider — eligibility checks need a rendering NPI.
4. Pick the service date. Usually today or upcoming visit date. NOT past dates — eligibility for past DOS is a different check.
5. Service type — pick from CPT or service type code (e.g. behavioral health = "MH"). Some payers respond differently per service type.
6. Submit. The platform sends a 270 eligibility request via Stedi or Availity. Response (271) typically returns in 5–30 seconds.
7. Read the response. The platform parses common fields:
   • Active coverage — yes/no on DOS
   • Plan type — HMO, PPO, EPO, Medicare Advantage, Medicaid managed care, etc.
   • Copay — per visit, varies by service type
   • Deductible — annual, individual + family, met YTD
   • Coinsurance — % after deductible
   • Out-of-pocket max — annual, met YTD
   • PCP — primary care physician on file (referrals from someone else may not be valid)
   • Prior auth required? — payer's general answer; specific service answer requires the auth tool
8. Save with the claim if you ran it pre-billing. The eligibility check ID attaches to the claim, gives you defense if denied.
9. Communicate to the practice / patient. If the patient has a $2000 deductible unmet, the practice should collect at time of service. If no coverage, patient is full self-pay or needs to update insurance.

Watch-outs

• Real-time eligibility isn't free. Clearinghouses usually charge per check. Don't pre-screen every patient daily for fun. Trigger on: new patient, insurance change, suspected lapse.
• Coverage as-of-today vs coverage as-of-DOS for a future visit. Future-date eligibility is a "best estimate" — the payer reports what they THINK will be true. Insurance changes happen mid-year. For high-cost services, re-check on the day of service.
• Medicaid eligibility flips monthly. Some state Medicaid plans (especially managed care) verify monthly enrollment. A patient covered Jan 1 may not be covered Jan 15. Re-check at month boundaries.
• The 271 doesn't always answer what you asked. Payer systems are inconsistent. If the response is incomplete (e.g. doesn't say copay), call the payer directly using the phone # on the card.
• Eligibility ≠ medical necessity. A patient can be eligible AND have the service denied for "not medically necessary." Eligibility just confirms the coverage exists; doesn't guarantee specific services are covered.
• Medicare eligibility has subsidies. Medicare patients may have a secondary (Medigap, employer retiree, Medicaid). Always check ALL insurances, not just the primary.

Related jobs

• Submit a claim — eligibility check should precede every submission
• Work Denial Inbox → Eligibility bucket — denials caused by eligibility need fresh re-verification

Something on this page doesn’t match what you see in the app? Email support@credentik.com and we’ll fix the guide.