Eligibility Verification Process SOP¶

Purpose¶

To establish a standardized process for verifying patient insurance eligibility and benefits before service delivery, ensuring accurate patient responsibility communication and minimizing claim denials.

Scope¶

This SOP applies to all patient access staff, registration personnel, and revenue cycle team members involved in patient eligibility verification.

Roles and Responsibilities¶

Role	Responsibilities
Registration Staff	Initial eligibility verification
Patient Access Manager	Process oversight, exception handling
Revenue Cycle Analyst	Eligibility reporting, denial analysis
IT Support	System maintenance, integration support

Definitions¶

Eligibility - Patient's insurance coverage status on the date of service
Benefits - Specific services covered under the patient's plan
Copay - Fixed amount patient pays at service
Coinsurance - Percentage patient pays after deductible
Deductible - Amount patient pays before insurance coverage begins

Step-by-Step Process¶

Step 1: Collect Insurance Information¶

When: At scheduling or registration

Actions: 1. Obtain insurance card (front and back) 2. Record all identifiers: - Member ID - Group number - Payer name - Plan type 3. Verify patient name matches card 4. Note effective dates

System Entry: - Enter in HIS/PMS registration - Scan card images - Flag incomplete information

Step 2: Verify Eligibility via NPHIES¶

When: Minimum 24 hours before service (scheduled) or at time of service (walk-in)

Actions: 1. Access NPHIES portal or integrated system 2. Submit eligibility inquiry: - Patient identifier - Date of service - Service category (optional) 3. Review response: - Coverage status - Effective dates - Network status

Decision Points:

Response	Action
Active, In-network	Proceed to benefits
Active, Out-of-network	Verify OON benefits, inform patient
Inactive	Verify with patient, check alternate coverage
Not found	Call payer, manual verification

Step 3: Verify Benefits¶

When: After confirming eligibility

Actions: 1. Query specific benefits for planned services 2. Check: - Service category coverage - Prior authorization requirements - Benefit limits (annual, lifetime) - Exclusions 3. Record benefit details in system

Key Benefits to Verify:

Step 4: Calculate Patient Responsibility¶

When: After benefits verification

Actions: 1. Determine applicable: - Deductible remaining - Copay amounts - Coinsurance percentage - Out-of-pocket maximum status 2. Estimate patient responsibility 3. Document calculation

Formula:

Patient Responsibility =
  Deductible (if not met) +
  Copay +
  (Allowed Amount - Deductible) × Coinsurance Rate

Step 5: Communicate with Patient¶

When: Before or at service

Actions: 1. Explain coverage status 2. Provide cost estimate 3. Discuss payment options: - Payment at service - Payment plan - Financial assistance 4. Obtain patient acknowledgment 5. Document communication

Required Disclosures: - Services not covered - Out-of-network implications - Prior authorization requirements - Estimated patient responsibility

Step 6: Document and Flag¶

When: After verification complete

Actions: 1. Update patient account: - Eligibility status - Benefits summary - Patient responsibility estimate - Verification date/time 2. Flag accounts for: - Prior authorization needed - Benefits limitations - Payment collection - Special handling

Step 7: Handle Exceptions¶

Scenarios and Actions:

Scenario A: No Coverage Found 1. Verify information accuracy 2. Check for alternate payers 3. Discuss self-pay options 4. Offer financial counseling

Scenario B: Prior Auth Required 1. Initiate auth request process 2. Inform patient of timeline 3. Document auth requirement 4. Follow up on approval

Scenario C: Benefit Limit Reached 1. Calculate remaining benefit 2. Estimate patient portion 3. Discuss options with patient 4. Document for claim notation

Quality Assurance¶

Daily Checks¶

All scheduled patients verified
Exceptions documented
Prior auths initiated

Weekly Metrics¶

Metric	Target
Verification rate	100% scheduled
Pre-service completion	> 95%
Eligibility-related denials	< 2%

Monthly Review¶

Denial analysis for eligibility issues
Process improvement identification
Staff training needs
System enhancement requests

System Integration¶

NPHIES Connection¶

Real-time eligibility queries
Automated response processing
Alert generation

HIS/PMS Integration¶

Patient demographic sync
Coverage data storage
Benefit documentation

BrainSAIT ClaimLinc¶

Eligibility validation in claim workflow
Denial prevention alerts
Automated re-verification

KPIs¶

Indicator	Target	Measurement
Pre-service verification rate	100%	Scheduled patients verified before DOS
Eligibility denial rate	< 2%	Eligibility denials / Total claims
Patient estimate accuracy	> 90%	Actual vs. estimated within 10%
Re-verification turnaround	< 24 hrs	Time from request to completion

Exceptions and Escalation¶

Exception Handling¶

Exception	Handler	Resolution Time
System downtime	IT Support	Immediate
Complex benefits	Supervisor	Same day
Patient disputes	Manager	24 hours

Escalation Path¶

Staff → Supervisor
Supervisor → Manager
Manager → Director (if regulatory/legal)

Revision History¶

Version	Date	Author	Changes
1.0	2024-01-01	RCM Team	Initial version
1.1	2024-06-01	RCM Team	NPHIES integration updates

Last updated: January 2025