What should you verify before every patient visit?

What should you verify before every patient visit?

Use this list in this order, because each answer decides how to read the next. The ID check comes first since every later step depends on it.

1. Card and photo ID. Scan both sides of the card and the ID. Compare the name, date of birth and member ID with what was keyed into registration.
2. Coverage on the date of service. Run the inquiry for the visit date, not today. Look for effective and termination dates in the response, because an "active" flag with no dates proves nothing.
3. Plan and payer. Note whether the plan is commercial, Medicare Advantage, Original Medicare, Medicaid or a Medicaid managed care plan. Pick the payer from the response, not from the name on the card.
4. Network status. Confirm you are in network for this plan product, not only for the payer's name. If the response does not show it, check the payer's portal or call.
5. Cost share. Record the deductible, the amount already met, the copay and the coinsurance for the service you are scheduling.
6. Authorization. Check whether the scheduled service needs approval, and start the request now if it does. The prior authorization guide covers the clocks.
7. Other coverage. Ask the patient about every plan and who the policyholder is, then run an inquiry on each. Coordination of benefits decides which pays first.

Save the response, or a screenshot of it, with the account. When a payer later says coverage had ended, that file is your proof.

When should the checks run?

Run the first check when the visit is booked and the second shortly before the patient is seen. Booking leaves time to fix problems. The second check catches a plan dropped since booking or a new second policy.

The eligibility verification service page explains the underlying transaction, and the front-end denial prevention guide sets the same checks in a hospital patient access chain.

What is different for a Medicare patient?

For Original Medicare you need the patient's Medicare Beneficiary Identifier (MBI), first and last name and date of birth. CMS lists three ways to check: a Medicare Administrative Contractor portal, a billing agency, clearinghouse or software vendor, or HETS directly. The Medicare payer guide covers the contractor side.

The HETS companion guide adds limits that matter for the date you enter. HETS accepts a date of service up to four years in the past and up to four months in the future, measured from the day the request is received. A date outside that range returns an AAA error with reject code 62. A request that contains the old claim number instead of an MBI is rejected, and the response is no better than AAA03 72, an invalid member ID.

A Medicare Advantage patient is a different payer. CMS says the response shows the patient's plan, the plan's enrollment dates and its contact information, and that you should direct benefit questions to that plan. The HETS companion guide also advises contacting the plan directly to confirm eligibility, since the indication of coverage does not imply payment by the plan.

Which denials does the checklist prevent?

It prevents the denials that start at the front desk. A name or date of birth that differs from the payer's file is a patient-not-identified denial. Coverage that had ended is a coverage-terminated denial. A second plan found late is a wrong-payer-first denial. A required approval nobody requested is CARC 197.

The catch-all for missing or invalid information is covered in the CO-16 code page, and the authorization denial is on the CO-197 code page. The after-the-fact steps are in the denial management playbook and the CO-16 fix guide.

How do you check a full schedule without losing the day?

Send a batch of inquiries a day or two ahead and have a person handle only the exceptions. The 270/271 transaction is a standard named in 45 CFR 162.1202, so every system that sends it uses the same format and can run it for a whole schedule. Software turns each response into flags: inactive, other coverage found, plan changed, authorization required.

The nine calls are made today, while the patient can still bring a new card. The same calls the next morning, with a patient at the desk, cost a visit. The family medicine billing page lists what these visits are billed with.

How Nucleus Align handles it

We run automated eligibility checks before the claim is built, so coverage problems surface while they can still be fixed, and we send claims within 24 hours of charge entry. Book a call to see how we would set up your front-end checks, or visit the blog.