Authorization & Eligibility
Eligibility & Benefit Verification
Eligibility and Benefit verification are important components of a strong Revenue Cycle Process. Patient plans and benefits change frequently, and it is important to establish a strong verification process while simultaneously eliminating redundancies in the process that are not cost effective. Lack of understanding 271 EDI results and poor processes can lead to Revenue Cycle pitfalls and delay cash flow. It is important to have a very well educated team. Our team of specialists consistently check for changes in benefits and plans.
We verify a wide range of data:
- Effective date and coverage details
- Individual patient eligibility
- Type of plan
- Payable benefits
- Non-covered procedures
- Claims mailing address
- Referrals & pre-authorizations
- Pre-existing clause
- Max-daily benefits
- Life time maximum
- Other related information
Our verification process checks procedure-specific coverage and benefits along with all out-of-pocket costs so that patients are aware of what is due before their visit. This process provides on-time patient payments and prevents unnecessary back-end collections, effectively increasing patient satisfaction and maximizing revenue.
While Prior Authorization is not a guarantee of payment, it is an extremely important step in ensuring that authorization and medical necessity requirements are met days in advance of the visit. Establishing a strong Prior Authorization process is critical to patients receiving care in a timely manner, provider satisfaction and eliminating the chance of other denials i.e. medical necessity, frequency etc.
Our authorization process includes the following:
- Visit dates should be within the effective and expiration date of the authorization
- Some payers require a specific appointment/visit date
- Appropriate CPT and HCPCS codes are submitted
- Appropriate levels are submitted
- Diagnosis codes meet payer medical necessity guidelines
- Plan of Care is well established and documented
- Diagnosis codes are well documented
- When applicable, the patient has undergone conservative treatment/therapy
- When applicable, MRIs are performed and interpreted
- When applicable the patient has had a psychological evaluation
- Establishing Peer-to-Peer reviews
We work closely with providers to educate them on payer policy changes and prior authorization requirements. We also educate providers on the importance of documentation as it allows for quick authorization approvals and reduces the chances of authorization denials upon submission.