Insurance eligibility verification process

Insurance Eligibility Verification is a process of verification of a patient’s active coverage with the Insurance company, and also to check if patient is eligible benefit for the procedure to which is scheduled in the facility/Doctor’s office/Ambulatory Surgical Center.

The following information has been verified during the insurance verification process.

1.Effective date
2.Patient policy status as of current date either Active or Inactive
3.Type of Plan like PPO, HMO, POS etc…
5.Deductible amount and how much patient met the deductible so far.
6.How much Ins will pay as per Provider Contract which means the %
7.Will the plans pays Primary left over if so, what will be the % they
8.will pay from primary coins.
9.Timely filing limit
10.Claims mailing address (Address of the Insurance)
11.Fax# if any

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.

In some cases eligibility Verification department need get 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.

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.

Finally eligibility verification is the important process. If this department works very well then provider can see the more cash flow which is good for everyone.

Beneficiary eligibility and claim status FAQ

Q: How do I obtain beneficiary eligibility information and/or claim status?

A: To access the status of a claim or a beneficiary's Medicare eligibility information (including the date of birth, date of death, entitlement dates, benefit dates, deductible, or coinsurance) use these options below.

Prior to providing services, obtain a copy of the beneficiary’s Medicare card and verify the beneficiary’s insurance information with either the beneficiary or his/her legal representative.

Part A providers
• Contact the Part A interactive voice response (IVR) system at 877-602-8816.

Part B providers

• Contact the Part B IVR at 877-847-4992.

Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.

Eligibility information through SPOT

First Coast Service Options Inc. offers such access through SPOT (Secure Provider Online Tool). With SPOT, providers may access Part A and Part B eligibility status as well as benefit eligibility for preventive services, deductibles, therapy caps, inpatient, hospice and home health, Medicare secondary payer (MSP), plan coverage data categories and claim status.

Q: How can I ensure that beneficiary identification information submitted on my claim matches information on file for the patient?

A: It is critical that beneficiary identification information submitted on claims is identical to the information found on the beneficiary's most recent Medicare card. Make a copy of the Medicare card for your records.

• If you are a laboratory, radiology department, or other entity to which the patient or their service(s) may have been referred, obtain a copy of the patient's Medicare card from the referring source prior to submitting your claim and verify the information indicated below.

Use the beneficiary's Medicare card to verify the following:

• Medicare number: Verify the beneficiary's Health Insurance Claim (HIC) number, ensuring it has not been changed.

• Beneficiary's name: Verify the beneficiary's name indicated on your claim is exactly as it reads on their Medicare card. For example, do not indicate "Betty" if the card reads "Elizabeth."

• Effective date: Verify the effective date of coverage.

• Date of birth: Verify the beneficiary's date of birth. Be careful not to transpose numbers, especially when entering HIC numbers.

• Part A and/or Part B: Verify which part of the Medicare program the beneficiary is enrolled, either A or B or both.

Q: What are the claim submission rules for a beneficiary who is admitted into a hospital prior to their Medicare Part A effective date?

A: There are special billing guidelines to follow when the beneficiary becomes entitled to Part A benefits in the middle of an inpatient stay. Pre-entitlement days are not counted for utilization or for the hospital’s inpatient prospective payment system (PPS) pricer. Furthermore, pre-entitlement days are not used for the cost report or for utilization in non-PPS hospitals, exempt units or skilled nursing facilities (SNFs). In this situation, the days are calculated based on the beneficiary’s Medicare Part A entitlement date through discharge/transfer/death.

The hospital may not bill the beneficiary or other persons for days of care preceding entitlement, except for days in excess of the outlier threshold. The hospital may charge the beneficiary or other persons for applicable deductible and/or coinsurance amounts.

Listed below are the claim submission guidelines for inpatient hospital admit to discharge claims (no outlier):

• Type of bill (TOB) -- Enter 111
• Admit date -- Enter the actual date of admission
• Do not enter the Medicare Part A entitlement date as the admit date
• Statement coverage period “From” date -- Enter the Medicare Part A entitlement effective date
• Do not enter the admit date as the coverage period “From” date
• Statement coverage period “Through” date -- Enter the end date of the inpatient stay
• Utilization days -- Enter the total number of days for the statement coverage period
• Do not report any pre-entitlement days as covered or non-covered
• Covered and non-covered days are reported utilizing value codes 80, 81, 82, and/or 83
Value code 80 -- Covered days
Value code 81 -- Non-covered days
Value code 82 -- Co-insurance days
Value code 83 -- Lifetime reserve days
• Diagnosis codes -- enter all diagnosis codes from admission to discharge/transfer/death
• Accommodation days/units -- Enter the appropriate number of units and charges as covered and/or non-covered for the statement coverage period
• Do not report the pre-entitlement days as covered or non-covered room and board units or charges
• Revenue codes -- 010X – 016X are appropriate for billing room and board
• Revenue code -- 018X is appropriate for billing a leave of absence (non-covered days and charges)
• Remarks -- Medicare Part A effective xx/xx/xx


The patient is admitted on April 25, 2016, and discharged on May 13, 2016. The patient’s Medicare Part A entitlement effective date is May 1, 2016. The claim should be billed as follows:
• TOB -- 111
• Admit date -- April 25, 2016
• Statement coverage period “From” date – May 1, 2016
• Statement coverage period “Through” date -- May 13, 2016
• Utilization days -- 12 covered days
• Accommodation days/units -- 12 covered units and covered charges
• Remarks -- Medicare Part A effective May 1, 2016

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