Eligibility verification
Eligibility verification is confirming, before or at the visit, that a patient’s insurance is active and covers the planned service — and what the patient will owe.
Updated
Eligibility verification is the front-end check that confirms a patient’s coverage is active on the date of service, that the plan covers the planned care, and what the patient’s share of the cost will be. It is often performed electronically through an eligibility inquiry and response (the X12 270/271 transaction).
It is the earliest opportunity to catch a coverage problem — before care is delivered and a claim is created.
In practice
A large share of denials trace back to eligibility problems: inactive coverage, the wrong plan on file, a non-covered service, or a missing authorization. Verifying eligibility up front is one of the highest-leverage ways to prevent downstream denials and protect the clean-claim rate.
Commonly confused with
- Prior authorization: Prior authorization is a payer’s advance approval of a specific service; eligibility verification confirms coverage is active and benefits apply.
- Coordination of benefits: Coordination of benefits determines which of several plans pays first; eligibility verification confirms a given plan’s coverage.