What eligibility verification is

Eligibility verification lets you check whether a patient has active insurance coverage before you submit a claim. Billing uses the standard EDI 270/271 format: you generate a 270 request, send it to the payer or clearinghouse, and upload the 271 response when it comes back. The response tells you whether the patient is covered, their copay and deductible, and the coverage dates.

Checking eligibility before you bill saves time. If the patient's coverage has ended or the information is wrong, you find out now instead of waiting weeks for a denial.

Checking eligibility from a claim

  1. Open the claim you want to check.
  2. Scroll to the Payers section.
  3. Click the Check Eligibility button.
  4. Billing builds a 270 request from the patient and subscriber information on the claim and downloads the EDI file to your computer.
  5. Send the 270 file to the payer or clearinghouse you use for eligibility checks.
  6. When the 271 response comes back, upload it against the request on the Eligibility page (see uploading eligibility responses). Once uploaded, the row next to the Check Eligibility button shows Eligible or Not Eligible.

What the response tells you

Once you upload the 271, Billing parses it and shows:

  • Coverage Status — Eligible or Not Eligible.
  • Plan Name, coverage begin, and coverage end dates.
  • Copay, Coinsurance, Deductible, and the remaining deductible.
  • Any error codes the payer returned.
  • A Benefits Detail table with service-level coverage information, when the payer provides it.

Example

You have a claim for a patient with Blue Cross insurance. Before submitting, you click Check Eligibility in the Payers section. Billing downloads the 270 file. You send it to your clearinghouse. The next day, the 271 comes back. You upload it, and the response shows the patient is Eligible, coverage started January 1, with a $250 deductible.

Tips

  • Check eligibility before submitting any claim you are unsure about. It takes a minute and can save weeks of follow-up on a denial.
  • If the response says the patient is not covered, check that the Policy ID and date of birth on the claim match the insurance card exactly.