The Ultimate Guide to Insurance Eligibility Verification


A person must use their insurance services when facing medical issues and needing hospital assistance. When an individual gets admitted and has insurance, the hospital billing team will do an insurance verification. It is an easy process to determine the patient’s insurance coverage and financial responsibility. The billing executives accomplish this process before they begin with the medical services.

Insurance verification can benefit the patient and the hospital in multiple ways. Let’s understand everything about insurance eligibility verification through this article:

What Is The Need Of Insurance Eligibility Verification?

Hospitals use insurance eligibility verification services when patients are admitted to their center for medical needs. Such verification helps the hospital in financial security and often prevents claim rejections. There can be instances when the patient’s insurance may have lapsed, and if the medical center provides services, it will be a loss.

Moreover, It is also good if the patient knows in advance whether their insurance will cover their medical costs or not. Simultaneously, it also aids in improving the hospital’s revenue cycle. If the patient has insurance, the hospital can collect the coinsurance or co-pays upfront, increasing their cash flow and minimizing collection delays.

And if the medical center does not go for the verification, below are some of the disadvantages:

  1. The medical center will give medical care without valid insurance.
  2. Without verification, the center cannot secure the authorization, which can result in claim rejection.
  3. If verification is present, informing the patient of their financial responsibility will be possible. It will eventually lead to money staying in the collections process.
  4. If a patient is informed later about the additional amount that is required to be paid, it can impact their relationship with the healthcare center.

Steps Involved In Insurance Eligibility Verification Process

Below steps involved in the process of insurance eligibility verification:

  1. The hospital obtains the patient’s information, such as name, date of birth, address, insurance company’s name, etc.
  2. The patient needs to provide insurance card details.
  3. The patient is added to the portal for checking the insurance details.
  4. The medical billing executive electronically checks insurance eligibility by choosing the service type and benefits.
  5. Different information is cross-checked during the verification process. It can be whether the policy is effective, needs pre-authorization, how much the patient may have to pay out-of-pocket, etc.
  6. If there is a pre-authorization, the medical center will forward the request.
  7. The hospital will inform the patient about financial responsibility.
  8. The hospital will collect the amount from the patient before the start of care.

If the above steps are correctly followed, the chances of the amount going to collections will be limited. If the verification process is not followed, the hospital will require help from outsourcing revenue cycle management services to figure out ways of controlling the revenue cycle.

What Are Some Of The Common Denials Due to Incomplete Insurance Eligibility Verification?

Some of the reasons for which an insurance company may reject the claim in case of no insurance eligibility verification are listed below:

  1. Claims can be rejected if there is a typing error in the information shared.
  2. If the mandatory information needs to be completed or included.
  3. If the medical executive needs to enter correct or complete patient demographics.
  4. If the coverage on the insurance has been exhausted.
  5. If the medical services the patient needs are not covered.
  6. If the patient’s coverage is terminated.
  7. In case the patient’s policy expires or is terminated.
  8. In case the insurance company requires a pre-authorization.
  9. If the policy is out of network coverage.

Bottom Line

Insurance eligibility verification is familiar and has been practiced for a long time. Doing such verifications in advance is beneficial for many reasons, including preventing losses. Medical centers can hire or outsource an experienced company to handle this work.

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