Eligibility verification
Eligibility verification is confirming, before or at the visit, that a patient’s insurance is active and covers the planned service — and what the patient will owe.
Updated
Eligibility verification is the front-end check that confirms a patient’s coverage is active on the date of service, that the plan covers the planned care, and what the patient’s share of the cost will be. It is often performed electronically through an eligibility inquiry and response (the X12 270/271 transaction).
It is the earliest opportunity to catch a coverage problem — before care is delivered and a claim is created.
In practice
Verifying eligibility up front is what catches the coverage problems that otherwise surface as denials: inactive coverage, the wrong plan on file, a non-covered service, a missing authorization. It is worth knowing what the check does and does not settle — the regulation defines a single inquiry as asking about any of three different things, “eligibility to receive health care under the health plan”, coverage, or “benefits associated with the benefit plan”, so a transaction that returned an answer has not necessarily returned the answer the visit needed.
HFMA publishes the measure as MAP Key PA-3, insurance verification rate, and attaches a caveat worth carrying: a successful verification is defined by the individual organization’s policy. Two practices reporting the same rate are not necessarily counting the same thing.
Commonly confused with
- Prior authorization: Prior authorization is a payer’s advance approval of a specific service; eligibility verification confirms coverage is active and benefits apply.
- Coordination of benefits: Coordination of benefits determines which of several plans pays first; eligibility verification confirms a given plan’s coverage.