Eligibility & Benefits Verification

Eligibility Verification:

The process of finding out / verifying if the patient has insurance coverage with a given insurance company is known as Eligibility Verification. If we need to verify Patient's who have Medical or Dental appointment, it is very essential that we verify their Medical or Dental Coverage only.

Compulsory Information Needed for Successful Verification:

Subscriber  or Patient's Information:

Subscriber Name

Subscriber DOB

Subscriber SSN

Subscriber Member ID

Patient Name

Patient DOB

Insurance Info:

Insurance Name

Insurance Phone Number

Provider Info:

Provider Name

Provider Tax ID Number

Provider License Number

Office Name and Telephone Number

What all does it involve?

Eligibility Check:

This involves, verifying if the patient is still eligible (policy is active) with that particular carrier.

Verifying the Member ID, Group#, Employer Name, Insurance Claim Mailing Address.

Benefits Check:

Verifying the Remaining Maximum's on the plan. This is the same as "How much of the Maximum amount has the patient utilized?"

Verifying Histories on certain procedures as this will determine if the patient can do some of these treatments or not, depending on the frequency limitations.

In addition we need to verify specific questions that the Client provides us with.

Each CLient will have their own set of questions, though they may be similar in nature.

When is Verification Done?

The process of Eligibility & Verification is most fruitful when it is done prior to the patient's appointment. This will give the doctor's office the ability to advice of their responsibilities. Also in case there is an issue with the eligibility of the patient, the office can contact the patient and find out if they have any other insurance that will cover their treatment.

It is always better to inform the patient of their responsibilities prior to treatment rather than after their treatment.

How often should we verify Eligibility and Benefits?

It is beneficial to verify Eligibility at least once a month (if the patient has an appointment coming up soon). Very of then people / employers change their insurance and if we do not check the eligibility status we may end up performing expensive treatment only to realize that the patient's insurance has changed or the patient is no longer eligible with that insurance company.

Once we have verified the Eligibility of an existing patient and all the information is same, it is good idea to verify the benefits at least once a year.

Now both of the above points on "How often we verify Eligibility & Benefits?" totally depends on you client so it is always essential that we follow their guidelines / requirements.

Why it is Necessary to Verify Eligibility & Benefits?

As discussed earlier, people may change their insurance at any time. Most of the people have insurance through their Employers and their employers may also change the insurance / insurance plan. at any time depending on, which insurance has the best benefits at the best price. So it is advisable to verify the patient's eligibility at least once a month to make sure they are still active with that insurance / group / Plan.

As for the Benefits, most insurance carriers generally update their benefits once a year, so it is advisable to verify the benefits of the patient's once a year. This will ensure that we have the correct benefits breakdown attached to the patient every time. Many Employers may have different levels of benefits for their employees depending on their designations. E.g., If a person gets promotion, his / her benefits level may change and so by verifying their benefits we will come to know of such changes.

Moreover, always remember it is better to inform the patient of their responsibilities prior to treatment than trying to make them pay for something their insurance denies after the treatment is performed.

Who Benefits from this Service?

It is the provider/Dentist/Doctors who benefits the most from this service. Because if we find out any problem with the patient's Eligibility or Benefits the Provider / Office Manager can advice the patient of their responsibilities, also out of pocket expenses prior to treatment.

The patient will also be happier to know of such expenses in advance so that they can then decide whether to go ahead with the treatment.