Eligibility denials are the most preventable denials in medical billing — and among the most common. A patient whose coverage lapsed, whose plan changed, or who was never in network to begin with turns a clean visit into an unpaid claim. Health XRCM’s insurance eligibility verification services confirm every patient’s coverage and benefits before the date of service, so your front desk knows exactly what will be paid, what the patient owes, and what needs authorization — before care is delivered, not after a denial arrives.
Eligibility verification is the process of confirming a patient’s insurance coverage and benefits before a service is provided. It checks whether the policy is active on the date of service, what the plan covers, how much of the deductible has been met, the patient’s copay and coinsurance, whether the provider is in network, and whether the planned service needs a referral or prior authorization. Verification is done electronically through EDI 270/271 transactions, payer portals, and direct payer calls for the cases that need a human on the phone.
Eligibility is where clean claims are won or lost. Verified coverage means fewer eligibility denials, fewer surprises for patients at checkout, more accurate patient cost estimates, and a front desk that isn’t spending its day on payer portals and hold music. It also feeds directly into our prior authorization and medical billing workflows, so nothing falls between the steps.
When should eligibility be verified?
At scheduling, again 48–72 hours before the visit, and on a recurring cycle for ongoing treatment — coverage changes mid-treatment more often than most practices expect.
What exactly do you check?
Active coverage on the date of service, plan type and network status, deductible met to date, copay and coinsurance amounts, coordination of benefits, and whether the service requires a referral or prior authorization.
Which payers do you verify?
Medicare, Medicaid — including New Mexico’s Turquoise Care MCOs — and all major commercial payers, through electronic eligibility transactions, payer portals, and direct calls where needed.
Stop losing claims to coverage you could have checked in advance. Call (505) 274-7878 or book a free assessment.
