02 — Capability · BC-1810.30
Eligibility & Benefits Verification
Know before the visit whether the patient is covered, by whom, in what order and for which services, so the right payer is billed and coverage surprises are found while they can still be fixed. Deciding a member's eligibility is the health plan's own capability.
- Insurance Verification
- Eligibility Checking
- Benefits Verification
In scope
- Electronic and manual eligibility checks against each payer
- Benefit, copay, deductible and coinsurance detail for the planned service
- Discovery of unknown coverage and coordination of benefits order
- Medical necessity screening and advance notices to patients
Out of scope
- Maintaining member eligibility as the health plan (see BC-1870.10)
- Requesting authorization for the planned service (see BC-1810.40)
- Applying for public coverage on the patient's behalf (see BC-1810.50)
Realized by · 2
- Epic · Patient Accesscore via BC-1810.30.10
- MEDITECH Expanse · Revenue Cyclecore via BC-1810.30.10
Used in · 2
Build it · 1
Decomposes into · 5
- BC-1810.30.10Insurance Eligibility VerificationConfirm with each payer, electronically where possible, that the patient's coverage is active for the date and type of service.
- BC-1810.30.20Benefit Coverage DetailRetrieve the copay, deductible, coinsurance, visit limits and network status that apply to the planned service, and record them for estimates and billing.
- BC-1810.30.30Insurance Coverage DiscoverySearch for coverage the patient did not report or did not know about, especially for self-pay and emergency patients, before the account is treated as uninsured.
- BC-1810.30.40Coordination of Benefits CaptureEstablish which of several coverages pays first, second and third, including accident and workers' compensation liability, and keep that order current on the account.
- BC-1810.30.50Medical Necessity ScreeningCheck planned services against the payer's coverage rules before they are performed, and give patients the required advance notice when a service may not be covered.