How Can You Verify Eligibility and Benefits Before Starting Prior Authorization?
Key Takeaways
- Eligibility and benefits verification prevents rejections or delays during the prior authorization process.
- Essential tools include insurance portals, eligibility systems, and patient-provided information.
- Following a systematic approach ensures accuracy and minimizes potential disputes.
Step-by-Step Guide: Verifying Eligibility and Benefits
Step 1: Gather Essential Patient Information
Start by collecting the patient’s core details, including:
- Full name (first, last, and middle initial if applicable).
- Date of birth.
- Insurance Member ID or policy number.
- Payer’s insurance name (e.g., Florida Blue, BCBS).
- The patient’s contact details for further clarification if required.
For example, during the process described in the transcript, the professional confirmed patient details such as Member ID and date of birth to ensure accuracy before moving forward with eligibility checks.
Step 2: Access the Insurance Portal or Eligibility Verification System
Log in to the relevant insurance provider’s portal or use third-party verification tools. Many systems require two-step authentication, so be prepared with the necessary credentials or device for security codes.
Key actions in this step include:
- Selecting the appropriate payer or health plan from a drop-down menu.
- Ensuring correct plan type selection, such as Medicaid, Medicare, or specific plan names like CMS (Children’s Medical Services).
- Entering patient details to retrieve real-time eligibility information.
As shown in the example for “Florida Blue,” verifying the plan type first prevents mismatches and ensures the eligibility check is routed correctly.
Step 3: Check Plan Type and Coverage Details
Once eligibility is confirmed, dig into the specifics of the patient’s benefits:
- Confirm coverage for the requested test, procedure, or service (e.g., outpatient services, diagnostic lab tests).
- Review the service codes, such as CPT or HCPCS codes, related to the authorization request.
For instance, during the growth hormone stimulation test (CPT code 80428), verifying benefits upfront revealed that authorization wasn’t required, saving time and resources.
Step 4: Validate Provider and Facility Information
Next, verify if the attending physician and service facility are in-network.
- Use the portal’s tools to search and confirm that the provider’s details match what the insurance accepts.
- Double-check the National Provider Identifier (NPI) to avoid unnecessary denials.
For example, in the case discussed, the staff ensured that the provider’s NPI and facility information aligned with insurance requirements before proceeding.
Step 5: Document Eligibility Results
After obtaining the eligibility details:
- Document the results in the patient’s medical record or system (e.g., ECW).
- Include a transaction ID or reference number for future reference.
- Store the confirmation in a secure location, such as local files or insurance verification systems.
Having this documentation readily accessible helps resolve disputes or questions from patients or insurers in the future.
What Did We Learn?
Verifying eligibility and benefits is a cornerstone of the prior authorization process. It minimizes errors, ensures coverage, and allows healthcare providers to offer timely care. By meticulously checking patient details, accessing insurance portals, and validating codes, providers can avoid surprises and establish a solid foundation for authorization requests.
FAQs
- What happens if eligibility isn’t verified before authorization?
- Lack of verification can lead to authorization denials or delays, increasing administrative burdens and potentially delaying patient care.
- What tools are commonly used for eligibility verification?
- Insurance portals, EHR systems, and dedicated verification tools like Availity or payer-specific platforms.
- Can prior authorization proceed if benefits are unclear?
- It’s risky to proceed without clarity. Always verify benefits to avoid unnecessary denials
Disclaimer
The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.
This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.
For tailored support and professional services,
please contact Staffingly, Inc. at (800) 489-5877
Email : support@staffingly.com.
About the Author : Monica Michael is a seasoned Prior Authorization Specialist with years of experience in streamlining insurance processes for healthcare providers. She is passionate about simplifying complex administrative tasks to help hospitals focus on delivering exceptional patient care.
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