Eligibility Mistakes That Delay Payment

Eligibility is a date, not a feeling

Coverage is true or not true on the date of service, for the plan that will be billed, for the provider who will be on the claim. A card in the wallet is a clue. It is not proof. An eligibility response from last month is a clue about last month. The check that matters is tied to the appointment date.

The 270 inquiry and the 271 response are the electronic version of that check. A response can say the member is active and still omit the copay, the remaining deductible, or whether a particular service needs an authorization. Staff who tell a patient 'you're covered' have said more than the transaction said, unless they read the benefit that was actually returned.

Mistakes that show up weeks later

The subscriber and the patient are swapped. A spouse's plan is billed under the patient's own ID, or a child's claim is sent with the child's name as the subscriber. The payer rejects or denies for member not found, and the front desk hears about it as a billing failure.

The plan year changed and the old payer ID is still in the demographic. The patient said 'same insurance' and meant the same company with a new group number. Claims go to a plan that no longer covers the date of service.

The visit is billed to a plan that is secondary. Coordination of benefits is not optional when another plan is primary. Sending the secondary first produces a denial that looks like a coverage denial and is actually a sequencing denial.

A service that needs a referral or an authorization is scheduled because eligibility came back active. Active coverage and permission to do the service are different facts. The eligibility page on this site is about the first fact. Prior authorization is the second.

What to capture before the patient arrives

The useful record is short. Which plan was checked, on what date, for which date of service, what the response said about active coverage, and what it did not say. If a person called because the electronic response was empty, the reference number and the name of the representative belong in the same place.

Copay collected at the desk should match the benefit that was verified, not the copay from the previous visit. If the response did not include a copay, the practice can say so and collect according to its own policy. It should not invent a figure from the card's logo.

• Patient and subscriber names as the plan has them.
• Member ID, group, and payer ID used on the inquiry.
• Date of the check and date of service.
• Active or inactive, and any other benefit the response actually contained.
• Whether a referral or authorization is still an open question.

What this does not settle

An eligibility response is not a promise of payment. Medical necessity, coding, timely filing, and the contract still apply. A clean eligibility check removes one family of denials. It does not raise a collection rate by itself, and this article does not claim one.

If the same eligibility denial returns after the check is in place, look at whether the check is being saved on the encounter that was billed, or on a different appointment. A check that nobody can find is the same as a check that never happened.