Eligibility Verfication in Medical Billing

How to reduce the denial


Eligibility Verification is a department in the Billing Company, which functions exclusively for the verification of a patient’s active coverage with the Insurance company, and also to check if he/she has an eligible benefit for the procedure to which he/she is scheduled in the facility/Doctor’s office/Ambulatory Surgical Center, and finally ensuring that the patient that is about to walk-in for the procedure is thoroughly eligible for that service from the Insurance Company’s perspective.


When you talk about eligibility, it is all about checking if the patient has an active medical/dental (depending on the service) policy with the insurance company, and also verifying the patient’s name, ID #, DOB, Subscriber of the policy, Group # are appropriate, and matching with what has been updated by the patient to us. Also, the policy effective date, type of policy and the insurance company functioning as primary/secondary/tertiary, claims mailing address need to be checked.


On benefits, it is the area of coverage, which the subscriber and the dependents are entitled to, by having an active policy with an insurance company. In other words, the procedures which are covered, and being authorized by the insurance company for payment are the benefits of the policy. It also covers ascertaining of the insurance company’s % of coverage of payment on a particular procedure, patient’s responsibility through co-pay/co-ins on that procedure.


In Eligibility Verification department, the other information to be ascertained is on the requirement of a Referral, and or Prior-authorization. So that once the procedure is over, a copy of the Referral/Prior-authorization should be submitted along with the claim with the insurance company for the claim to be paid. One other responsibility of the pre-certification department is to check if the Provider is participating with the insurance company as there are different levels of benefits for in-network/out-of-network Providers from the insurance company.


The Eligibility Verification department department minimizes the denial of the claims to the maximum extent by checking out the eligibility, and benefits of the patient before hand ie., before the service is being rendered to the patient. Less number of denials is equal to more number of clean claims, which means a healthy collections, and higher inflow of payment.

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Ultimately, the Eligibility-Verification department plays a vital role is curbing the denial of the claims, and bringing in more money to the Doctor’s office, and Billing office as well.

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