Medical Insurance Eligibility

Verifying a patient's medical insurance eligibility tells a physician's office if the patient is covered and eligible for benefits on the day services are rendered. This streamlines the medical billing process for providers and details benefit information for members.

Significance

• Verifying eligibility tells a provider what type medical plan the patient has, when the patient was effective and if the policy has terminated, as well as what procedures are covered and if the patient is responsible for a deductible or copay (usually collected at the time of service).

Process

• Medical insurance eligibility is verified by calling the insurance company. Some insurance companies have interactive web tools for physicians to determine eligibility online.

Considerations

• Benefits can be retro effective or retro terminated. This often occurs with union or trust plans that offer benefits to employees based on the number of hours worked. Retro effective and termination dates are also common when working with Medicaid programs.

Solution

• Patients should try to verify, or ask the physicians office to verify, ahead of time whether they remain eligible under their plans, whether the service or procedure will be covered and what the out-of-pocket costs will be so they can plan accordingly.