Eligibility & Verification
Before relying on coverage information, staff should first do this on every patient with a SSN or BIC ID number.
What is checking the Medi-Cal website?
To avoid billing denials, staff should make sure this is done for every patient with more than one plan.
What is adding all the appropriate coverages?
This response must be reviewed carefully because it often contains coverage status, payer details, and important billing information.
What is reading the RTE response?
To prevent denials, staff should notify the ER visit to the insurance, and or this contracted physician network when required.
What is the IPA/medical group?
If a patient is receiving this type of care, that coverage must be added correctly to avoid billing issues and must be listed primary.
What is hospice coverage?
This questionnaire must be answered correctly to determine whether Medicare is primary or secondary for every ED visit.
What is the MSPQ?
If a plan is no longer valid, staff should do this in the account to prevent the wrong payer from being billed.
What is terminating inactive coverages?
Staff should review this section to determine which insurance should be billed first, second, or third.
What is coordination of benefits?
This field should be answered correctly to help determine the proper filing order for claims.
What is the covered through field?
This federal coverage often has a strict reporting requirement for ER visits within a limited timeframe.
What is the VA?
Failing to read this electronic eligibility response can cause missed details such as inactive coverage or payer instructions
What is the RTE response?
Missing this type of coverage may result in denials when end-of-life services are involved.
What is hospice coverage?
To determine the correct claim filing order, staff must review COB information along with this additional key field.
What is the covered through field?
To avoid denials, required payer or medical group notifications should be completed in this manner.
What is timely or on time?
This Medicare-related questionnaire helps identify employment status and other factors that affect payer responsibility.
What is the MSPQ? (Medicare Secondary Payer Questionnaire)
One denial prevention step is verifying not just coverage status, but also plan information directly on this source.
What is the payer website? (Medi-Cal, Availity, OneSource, Blue Shield, Alignment, CHG, etc)
Staff should ensure every active insurance plan is entered, including primary, secondary, and this additional level when applicable.
What is tertiary coverage?
If staff do not read the Coordination of Benefits correctly, they may bill the wrong payer first, causing this type of issue.
What is a denial?
For veterans, the ER visit should be reported within this timeframe to prevent payment issues.
What is 72 hours?
This action helps prevent denials when a patient’s previous insurance should no longer be billed.
What is terminating coverages that are no longer active?
This denial prevention process includes checking the website, reviewing RTE, and confirming all coverage details before billing.
What is insurance verification?
If all active plans are not added, claims may deny because the account does not reflect this complete insurance picture.
What is all appropriate coverages?
Correctly answering the Coordination of Benefits and the covered through field helps establish this claim rule.
What is the filing order?
In addition to notifying the insurance, staff may also need to notify this organization responsible for the patient’s assigned care network.
What is the IPA/medical group?
This special type of coverage and this federal payer both require extra attention because missing them can lead to avoidable ER denials.
What are hospice and VA coverage?