What is eligibility verification?
Eligibility verification confirms, before a service, that the patient's insurance is active and what it covers: the plan, network status, deductible, copay and coinsurance.
Eligibility and benefits
- Patient
- Alex Sample
- Payer
- Example Health Plan
- Checked
- 03/12/2026 for service on 03/14/2026
- Status
- Active, Gold PPO, in network
| Benefit | In network | Remaining |
|---|---|---|
| Deductible, individual | $1,500 | $620 |
| Office visit copay | $30 | |
| Coinsurance, after deductible | 20% | |
| Out-of-pocket maximum | $6,000 | $5,180 |
- With $620 of deductible left, the patient will likely owe the full allowed amount for today's services. That's worth telling them before the visit.
Coverage problems are the most preventable denials. A patient who changed plans, a member ID with a typo, or a policy that ended last month all produce denials that a check before the service would have caught.
What to verify
- Active coverage on the date of service, not just today.
- The plan and network: in network or out, HMO or PPO, Medicare Advantage or original Medicare.
- Benefits for the service: deductible remaining, copay, coinsurance, visit limits, and whether prior authorization is needed.
- Other coverage, for coordination of benefits.
- Special status, such as QMB or hospice, that changes what can be billed.
How it’s done
The 270/271 transaction answers most of this in seconds. When a payer’s 271 is thin or missing, the answer comes from its portal or a phone call. When coverage comes back inactive, insurance discovery looks for other plans.
When to check again
Before every visit or delivery, at the start of each year, and on a schedule for patients with recurring services. Coverage changes more often than patients mention.
Run your revenue cycle as workflows.
We are working with a small group of billing and operations teams to shape worklist. Tell us where your work gets stuck, and we'll show you how it would run.