Verify Health Insurance Coverage & Eligibility: A Comprehensive Guide

Members call insurance companies before seeing a physician to make sure their services will be covered. Is the provider participating with the health plan? What benefits are available to them? Providers also call insurance companies to determine whether a patient is covered. Health insurance companies will ask many questions before they release information about a patient, because they are required to do so by HIPAA (the Health Information Portability and Accountability Act of 1996).

Instructions

• 1

  Gather information. Have a copy of the member ID card ready. If you are a provider, you will need your tax ID or NPI number. You will also need personal health information (name, date of birth, etc.) before the insurance company will confirm benefits or eligibility.

• 2

  Call the insurance company. Contact information for providers and members is listed on the back of the member ID card.

• 3

  Specify the reason for the call. Are you a member or provider? Are you determining benefits or checking eligibility?

• 4

  Confirm personal health information about the patient. They will ask for the member's name, date of birth and policy number. In order for the insurance company to release information, your answers to their questions must match their records.

• 5

  Verify eligibility. This is the time to ask the representative if a patient is covered. What day did coverage become effective? Has the policy terminated? Were there any breaks in coverage for the patient?

• 6

  Verify benefits. Ask the representative if a specific procedure or medication is covered. Does this plan have routine-care benefits? Are prior authorizations for a procedure needed?