Verifiying patient insurance eligibility details - Medical billing - important process


During patient registration, it is important for front office staff to identify whether a beneficiary’s expenses should be covered by other insurance before, or in addition to, Medicare. This information helps the office determine who to bill and how to file claims with Medicare.

Patient insurance eligibility verification

This is not an easy task. There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays and when. Depending on the type of additional insurance coverage a patient has (if any), Medicare may be the primary payer for a patient’s claims or be considered the secondary payer.

The office staff should:

* Copy the Medicare card and/or other insurance cards.

* Obtain essential patient information through use of completed medical information/history and insurance forms.

* Determine Medicare eligibility.

* Determine “other” insurance coverage, claim submission guidelines and limitations to coverage.

* Determine the proper order of claim submission, who is primary and who is secondary payer. Obtain appropriate information to allow the claim to be submitted to the appropriate insurance payer.

A good practice to incorporate into the patient screening process is to make copies of the patient’s insurance card(s).


Verification is important since the information from the Medicare card should be obtained during the patient’s initial visit. Medicare also recommends that office personnel periodically verify a beneficiary’s insurance information to determine if any changes have occurred. Rev. 9/2010 3 Patient Registration/Screening

Pay close attention to:

 *Exact patient name.

* Claim number.

* Type of insurance coverage.

* Effective date of coverage.

Claim rejections or denials could occur if complete information is not obtained and supplied on the Medicare claim form submitted.

The accuracy and verification of the Medicare card information is extremely important because this information will be used on many claim forms and medical documentation materials throughout the patient’s history with the provider’s office.

Mistakes in patient information can carry over to Medicare claims, causing claim rejects, delays and even denials. These mistakes cause more work and can be quite costly for an office.

Many offices also collect information such as health status and previous condition/injury information, spouse and/or emergency contact information, and information about the events surrounding the accident or condition. The provider should also have the patient’s signature or the patient’s authorized representative on file to authorize the release of any medical or other information necessary to process claims submitted to Medicare.

Reminder: Item 12 or the electronic equivalent authorizes medical information to be released and Item 13 or the electronic equivalent authorizes the claim to be forwarded to a Medigap insurance plan.

Verification of correct patient information can also help protect providers from potential Medicare fraud in cases where individuals are attempting to falsely represent themselves as Medicare beneficiaries. Providers should always ask their patients if they have changed their address or legal name since they last visited their office. Many offices now ask for a valid photo ID when registering a new or established patient or in cases where the identity of a current patient is in question.

Something to consider with a Medicare patient: Just because the patient is carrying a red, white and blue Medicare card does not guarantee that the patient has Medicare Part B benefits. Under Medicare Part B, the patient must pay a premium to have Part B entitlement. If the patient chooses to discontinue the Part B Medicare coverage for whatever reason, they may still continue to carry the Medicare card. It is extremely important to verify the patient’s Medicare eligibility and never “assume” that possession of the card is proof of Medicare eligibility.

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