One-Stop Solution For Revenue Cycle Management Services


Make Your Eligibility Checks Complete with Proper Verification

The insurance eligibility and benefits verification services entails verifying the patient’s insurance. You should focus on this healthcare revenue cycle service because of its impact on the hotspot areas of revenue cycle solutions, which includes, but are not limited to AR billing, denials, and payment delays. To meet your financial goals and succeed in business, you must excel in all aspects of Healthcare rcm services.

A patient’s health insurance verification, is the foremost procedure of your RCM but many misses it to be done correctly. You can’t completely run away from the denials but with proper management of the software system, you can reduce the number to some extent. The next factor to consider that is causing poor eligibility checks is due to lack of information availability.

Reading through the article you can better understand how your eligibility checks need to be.

Note for new bees!

If you’re a first-time provider submitting the insurance claims then you may receive the following outcomes; submitted, pending, turned down, or approved. If you discuss the reasons for your claim’s denial most are due to improper paperwork and the reasons include,

  • Under documented patient information
  • Expired policy
  • Mismatched data
  • Closure dates
  • Billing claims errors

 A long-serving provider who wants to give service to a non-emergency case needs approval from the insurance company by prior authorization which should be done before the date of service. As a part of your admission getting approval has become mandatory in your service.

Why claims eligibility check must be your top priority?

It must be in your protocol to check the eligibility status of your patient’s insurance status which approves whether the policy is current and appropriate for the service that you are going to render.

When you think about the benefits that are involved in it, you can neglect the time consumed in these steps as the final result outcome is for the provider. With the surety obtained by checking eligibility and benefits verification services, you can get proper and assured payments without any delay, which is valuable for your healthcare.

The ideal verification system and regulations you missed out

Discovering the insurance eligibility process can be extremely challenging for a long-term care center since each state has different regulations and protocols that are being followed for the same. But with the health insurance verification system providers can get complete access to the patient information and their eligibility criteria within a few clicks.

You might think about how the state rules affect your verification, but consider Massachusetts and Oklahoma that is a thousand miles away from each other, the steps included in the verification also are far away from one another. Massachusetts, norms demands providers to make eligibility via the POSC in compliance with the Mass health program. Whereas when you’re in Oklahoma, you can make a call to a toll-free number for acquiring the patient’s information.

How CMS helps you in this process?

Health providers need to access the HIPAA eligibility transaction system which retrieves eligibility data and also get detailed benefits about verification to the providers. CMS also makes an effective part in this by making sure the providers get notified if the system is corrupted, and giving them alternative support desks for their use.

Whatever your patient’s insurance policy or wherever they are from the rules may differ for their insurance claims and you must not forget about verifying eligibility and benefits verification services without being exhausted. To facilitate this particular need the data of patient information is available in the eligibility verification system all time.

Sneak peek to succeed in your insurance verification 

When you want to maintain clarity then never hesitate to learn the process. For understanding the protocols involved in this process you can utilize the resources available about the eligibility checks but make sure your working staff’s in healthcare is equally aware of the protocols and procedures involved in it. 

The main reason to bring up this concept is they are the ones who will be dealing with your patients, and the fact that your patients either don’t remember the procedures involved within the eligibility and benefits verification services makes the necessity.

Make use of manuals

The complex nature involved with the steps and also the ever-changing rules for every insurance policy makes it difficult for the patients to understand why there is a deductible or from which pocket should this dollar needs to be passed and the ultimate questions will be moved to your staff’s desks. Answering these doubts is part of your duty, if you fail to do it then there might be unnecessary patient-provider conflicts which reduce the ongoing trust between you either.

If you want to escape from this issue then the solution for this is maintaining a protocol book for your eligibility checks this allows everyone to go through the procedure. Make it mandatory to train your staff about the matter of subjects. If you don’t have a training team for it then try utilizing the software systems which can be inbuilt with training programs and resources about the procedures.

You can also make use of state manuals that showcase pictorial depictions of how the online mode of checkup is done.

Steps you must never miss out

As discussed many healthcare personnel use health insurance verification as their first level of assurance to get payments from their patients. This check will give details about the coverage and if the plan type will give exclusive coverage for your treatments.

When you ask your patient’s about their insurance plan, many won’t know exactly about them, the reason is for many of them their employers will cover the insurance plan and they are not aware of it completely. So verifying plans will help you to rectify the mistakes that are because of insurance claims denials.

It is well evident how important the task of information collection is. Then following the steps with a detailed protocol can help you in gathering the information correctly. Here we have enlisted some important steps.

  • Gather patient insurance information 

Make sure your billing team is working on asking questions, without which you can’t expect answers to your doubts. Collect all relevant information without missing anything. To make your task simplified use this important checklist that needs to be twice checked.

  1. For personal details: Patients name, birth date, and address
  2. For insurance details: insurance Payor, insurance member id number, and Payors contact number
  3. Authorizations if needed.
  4. Referrals if required.
  5. In-network or out-of-network details
  6. Copay, Coinsurance, and Deductibles if applicable
  7. Policy effective date
  8. Coordination of benefits
  9. Out of pocket

You will be in a tricky situation when two or more insurance policy comes into the limelight. As most patients have many policies you need to find details of all of them and save them for your reference. The best way is to collect them and store them in system-centric software.

  • Have a backup for all records

When you’re dealing with lots of information in your hand, you inevitably make blunders. But if you have a copy of the same in your storage, it can be used to rectify these mistakes. This can also give your staff to have a double check option of their claims before the submission. That too claims denials that occur with even a single mismatch of documentation, having a backup will be very useful for future references.

  • Always maintain interaction with your Payor

“I got the insurance card, I can use the same for my lifetime” if you ever had this thought in your mind then no one can stop you from receiving denials. Insurance policy might change over time, using the information you collected from months or years before will not guarantee you getting final payments. Thus it’s your sole responsibility to call your Payor to check the insurance status of your patient. You must not end the process there updating the information in your software will help with verification whenever needed.

  • Be efficient with your contact details

One particular care that needs to be given is contact information that too with the address, if you fail in this particular then you will be dealing with unwanted denials. If you feel you need assistance feel free to contact Practolytics, by outsourcing insurance eligibility verification services with us, we make sure your claims get paid at the first go.


Eligibility and benefits check is crucial to get information about the insurance, for a smoother and smarter check you need to have understanding about the procedures involved, next to that a fully supportive software is important which can work on the pending claims and which tracks insurance data appropriately.

The impact of using insurance claims that are non-coverage to your services can cause loss to your healthcare that’s why we at Practolytics partnered with AdvancedMD gives you a fully supportive EMR system.

If your need assistance in working on your eligibility checks feel free to outsource insurance eligibility verification services with us.


prior authorization guide-practolytics


ALSO READReduce Your Workload by Outsourcing Prior Authorization