Why this step decides whether the claim gets paid
Coverage and authorization failures are among the most preventable causes of denied claims, because the information needed to avoid them is available before the encounter. When verification is skipped or rushed, the practice absorbs the cost of a service that was never payable.
Eligibility Verification & Prior Authorization capabilities
Real-time and batch eligibility checks
Coverage confirmed through payer portals and the HIPAA X12 270/271 eligibility transaction set, run in advance of scheduled visits rather than at check-in.
Benefit detail capture
Copay, coinsurance, deductible status, out-of-pocket accumulation, plan effective dates, and coordination of benefits where a secondary payer exists.
Prior authorization submission
Authorization requests prepared with the clinical documentation each payer requires, submitted through the payer's designated channel, and escalated when a determination stalls.
Authorization tracking to expiry
Approved authorizations logged with reference number, approved units or visits, and expiry date, with alerts before units are exhausted.
Referral management
Referral requirements identified for plans that mandate them, including HMO products where a missing referral makes the claim unpayable.
Documentation in your PM system
Verification results and authorization numbers written back into your practice management or EHR system so billing staff and clinicians see the same record.
Our eligibility verification & prior authorization process
Schedule intake
We receive the upcoming appointment schedule from your PM system or worklist.
Verify coverage
Eligibility is confirmed with the payer, including plan type, effective dates, and any coordination of benefits.
Capture benefit detail
Copay, deductible status, and patient responsibility are recorded for front-desk collection.
Identify auth requirements
Planned services are checked against payer authorization and referral rules for that specific plan.
Obtain authorization
Requests are submitted with supporting clinical documentation and followed until a determination is issued.
Document and hand off
Authorization numbers, approved units, and expiry dates are entered in your system before the date of service.
Eligibility Verification & Prior Authorization questions answered
Eligibility verification is the process of confirming with the payer that a patient's coverage is active on the date of service and determining what that plan covers. It establishes plan type, effective dates, copay and deductible status, coordination of benefits where more than one payer exists, and whether the planned service requires prior authorization or a referral.
Common practice is to verify shortly before the appointment so the result reflects current coverage, since eligibility can change at month boundaries, on plan renewal, or when employment ends. For services requiring prior authorization, the requirement should be identified far enough ahead that the authorization can be obtained before the visit.
Eligibility verification confirms that coverage exists and what the plan covers. Prior authorization is a separate approval from the payer for a specific planned service, granted in advance. A patient can be fully eligible and still have a claim denied because a required prior authorization was never obtained.
X12 270 and 271 are the HIPAA-standard electronic transactions for eligibility inquiry and response. The 270 is the request sent to the payer and the 271 is the payer's response describing coverage and benefits. They allow eligibility to be checked electronically rather than by telephone or portal lookup.
No. Authorization requirements are set by each payer and vary by plan and by service. They are more common for advanced imaging, elective surgical procedures, durable medical equipment, specialty pharmacy, and some behavioral health services. Requirements must be checked against the patient's specific plan rather than assumed.
An expired authorization generally will not support payment, and the service may need to be re-authorized before it is performed. We record approved units and expiry dates when authorization is obtained so the practice is alerted before an authorization lapses.