Verify a patient's eligibility before their appointment

For: Practice Admin or front-desk staff · Time: 1–2 min · Frequency: Before every new-patient visit; for established patients with insurance changes

Trigger

A new patient is scheduled. Or an established patient said their insurance changed. Or you want to confirm coverage before a high-cost service (psych testing, IOP intake, etc.).

Outcome

You know: is the patient covered on the visit date, what's their copay, where do they stand on deductible, is prior auth needed for what you're planning to do.

Where

• RCM → Eligibility tab

Steps

1. RCM → Eligibility → New Check.
2. Enter patient info:
   • Name, DOB
   • Member ID (from their card)
   • Payer name
3. Pick the provider seeing them.
4. Pick the service date. Today (for today's visit) or upcoming.
5. Pick the service type — "Mental health" for psychotherapy, "Office visit" for E/M, etc.
6. Submit. Real-time check returns in 5–30 seconds.
7. Read the result:
   • Coverage active? Yes/no.
   • Plan type (HMO/PPO/EPO/Medicaid managed care/Medicare Advantage).
   • Copay for the service type.
   • Deductible — annual, met YTD. If unmet, patient pays full allowed until met.
   • Coinsurance — % patient owes after deductible.
   • Prior auth required? — for some services, the payer will say yes.
8. Save with patient. The result attaches to the patient record so the agency can reference it on the claim.
9. Communicate to patient. If they have an unmet deductible, tell them at check-in what their share will be — avoids surprise bills later.

Watch-outs

• Eligibility checks usually cost a small fee per check. Don't run it daily for the same patient. Once per visit is plenty; once at intake for established patients.
• Real-time isn't always accurate. Payer eligibility responses can be 24 hours stale. For high-stakes services, also call the payer member services line.
• Some plans don't return copay info via the 270/271 transaction. If the response is incomplete, the agency or front desk needs to call the payer directly.
• Medicaid switches monthly. A patient covered by Medicaid in May may have a different managed care plan in June. Re-verify at the start of each month for Medicaid patients.
• Self-pay patients don't need eligibility. Save the cost. Just make sure their billing-class is set to self-pay so the agency doesn't try to file a claim.

Related jobs

• Check claim status — eligibility issues are a common cause of denials

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