Eligibility verification worksheet
A downloadable CSV structure for recording the coverage, benefit, and authorization facts from an eligibility check — without embedding patient data in the example.
CSV · Reviewed 2026-07-18
Download and use
The download contains headings and blank rows only. The examples below use fictional operational references so you can see the intended structure without copying patient data.
Column guide
Internal reference
Use a non-PHI internal work reference.
Payer
Payer or plan name.
Plan
The specific plan or product to be billed.
Coverage active
Yes or no for the date of service.
Effective dates
Plan effective and termination dates.
Network status
In-network or out-of-network for this plan.
Primary/secondary
Order of coverage where more than one plan applies.
Authorization required
Yes, no, or unknown for the planned service.
Estimated patient share
Estimate from the allowed amount; label it as an estimate.
Verified date
Date the eligibility response was obtained.
Fictional example
| Internal reference | Payer | Plan | Coverage active | Effective dates | Network status | Primary/secondary | Authorization required | Estimated patient share | Verified date |
|---|---|---|---|---|---|---|---|---|---|
| ELG-001 | Example payer | Example PPO | Yes | 2026-01-01 to 2026-12-31 | In-network | Primary | No | Estimate: copay only | 2026-07-15 |
| ELG-002 | Example payer | Example HMO | Yes | 2026-03-01 to 2026-12-31 | In-network | Primary | Yes — pending | Estimate: deductible + coinsurance | 2026-07-16 |
Working instructions
- 1Confirm coverage, benefits, and any authorization requirement from the payer's eligibility response and policy before relying on this worksheet.
- 2Do not enter patient names, identifiers, diagnoses, or claim details in an unsecured copy of this file.
- 3Record estimates as estimates; the final patient responsibility is set when the claim adjudicates.
- 4Store the payer's eligibility response and reference number in the approved secured system.