Insurance Eligibility Verification Services for Medical Practices
Verify coverage, copays, and deductibles before every patient visit so your team starts each day knowing exactly who is covered.
- HIPAA-Compliant
- U.S.-Based Experts
- Free Practice Audit
How Our Insurance Eligibility Verification Process Works
Schedule Upload
We receive your upcoming appointment schedule daily, either through your practice management system or a simple file transfer. We start verification 24 to 48 hours before each appointment.
Real-Time Verification
We verify each patient's benefits directly through payer portals and real-time eligibility systems. For complex plans or secondary coverage situations we call the payer directly to confirm the details.
Results Delivered to Your Team
Your front desk receives a verification summary for each patient before they arrive. The summary includes everything they need to collect the correct amount and flag any issues that need to be addressed before the visit.
Issue Follow Up
If we find a problem such as inactive coverage, the wrong plan, or an authorization that is needed, we alert your team immediately so the appointment can be handled correctly rather than resulting in a denial after the fact.
Denials That Start with Eligibility
Every one of these can be caught before the patient is seen. If one is already on your remittances, our Denial Code Lookup explains it.
| Denial code | What it means | Read more |
|---|---|---|
| PR 27 | Coverage ended before the date of service | PR 27 guide |
| CO 22 | Another plan should have been billed first | CO 22 guide |
| PR 119 | The plan's benefit limit for the period has been used up | PR 119 guide |
| CO 109 | The claim was sent to the wrong payer | — |
| CO 31 | The payer cannot identify the patient as its member | — |
| CO 197 | Authorization was required and never obtained | Prior authorization services |
Coverage Details a Basic Check Misses
An active policy is only the first answer. These are the details that decide whether the claim is paid.
Plan type
Medicare Advantage or Original Medicare
A patient who shows a red, white, and blue Medicare card may actually be enrolled in a Medicare Advantage plan. Billing Original Medicare for that patient gets the claim rejected, so we confirm which one is active on the date of service.
Dual coverage
Coordination of Benefits
When a patient has two plans, the order matters. We confirm which plan is primary and whether the payer's records are current, because an outdated record holds up payment until the patient updates it.
Benefit limits
Visit Limits and Carve-Outs
Therapy visits, chiropractic care, and behavioral health often have yearly visit limits or are managed by a separate company. We check what has already been used and who actually administers the benefit.
Patient cost
Deductible Timing
Deductibles reset at the start of the plan year, which is January for most plans but not all. A patient who paid nothing in December may owe the full visit in January.
Network
Network Status
Being contracted with an insurer does not mean you are in network for every plan it sells. We verify the patient's specific plan and network, not just the insurer's name.
Referrals
Referral and PCP Rules
HMO plans and some point-of-service plans require a referral from the assigned primary care provider. We confirm who that provider is and whether a referral is on file.
Why One Check Is Not Always Enough
Most practice management systems can run an electronic eligibility check, known as a 270/271 transaction, and for a straightforward plan that answer is enough. It confirms the policy is active and returns basic copay and deductible figures.
What it often leaves out is the detail that decides whether the claim is paid: whether this specific service needs authorization, how many therapy visits remain, or which plan is primary. For those we go to the payer portal or pick up the phone, and we record who confirmed it and when, so there is a trail if the payer later disputes it.
Verified benefits also set up everything that follows. They tell the front desk what to collect, tell us when to start a prior authorization, and remove one of the most common causes of denials before a claim exists. When a denial does get through, it goes to our denial management team with the verification record attached.
Free Billing Tools
Frequently Asked Questions About Eligibility Verification Services
Insurance eligibility verification is the process of confirming that a patient's insurance is active and understanding the specific benefits that apply to their upcoming visit. This includes copays, deductibles, coverage limits, and whether any prior authorizations are required.
We verify patients 24 to 48 hours before their scheduled appointment. This gives your team enough time to address any issues before the patient arrives rather than discovering problems at check-in or after a claim is denied.
Yes. We scale with your practice volume. Whether you have 20 appointments a day or 200, we verify every patient on your schedule.
We flag it immediately and notify your front desk so they can contact the patient before the visit. The patient can either provide updated insurance information or be informed that they will need to pay out of pocket, avoiding a claim denial entirely.
Yes. We verify both primary and secondary insurance for patients who carry dual coverage and document how coordination of benefits will apply to the visit.
We verify eligibility across all major commercial payers, Medicare, Medicaid, and Medicare Advantage plans. If a payer has a portal or real-time eligibility system, we use it.
Eligibility verification confirms that a patient's coverage is active and what the plan will pay for. Prior authorization is a separate approval the payer requires for specific services before they are performed. Verification comes first, because it is the step that reveals whether an authorization is needed.
For a simple visit on a straightforward plan, usually yes. An electronic check confirms active coverage and basic copay and deductible amounts. It often does not show visit limits, benefits managed by a separate company, or authorization rules for a specific procedure, so those are confirmed through the payer portal or by phone.
Related Services
Prior Authorization
Approvals secured before procedures
Denial Management
Denial analysis, appeals, and prevention
Revenue Cycle Management
The full cycle, managed as one process
Medical Billing Services
End-to-end billing for independent practices
Provider Credentialing
Payer enrollment handled end to end
AR Management
Aged AR recovery and payer follow-up
Small Practice Billing
Billing built for one to five providers
Medical Billing and Coding
Certified coding that holds up to payer review
Automate Your Verification
Contact Astral Medical Services today to set up a robust, automated eligibility process.