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How to Check Health Insurance Eligibility Electronically Online

March 14, 2024
Woman explaining eligibility and benefits

Why Is Checking for Health Insurance Eligibility Important?

Imagine selecting a doctor, seeking treatment, receiving a diagnosis, and getting on a treatment plan, only to find out you are solely responsible for all the costs. As a patient, this would be detrimental financially. It’s an easily avoidable mistake if providers check insurance eligibility before the patient receives treatment.

Medical insurance eligibility verification is when providers check the patient’s insurance to determine if the patient has medical coverage, is in network with the provider, what part of the costs are the patient’s responsibility, and what their insurance plan will cover. This information can save the patient money and make the billing process easier for the provider if done as the first step in the patient intake process. It can also benefit providers by ensuring they’re promptly and accurately reimbursed for services, improving their revenue cycle management.

Ensure Accurate Billing & Prevent Claim Denials

Making sure the billing process is smooth from start to finish is vital to receiving prompt payment. When health insurance eligibility is verified before the patient is seen, some payments, such as copayments, can be collected upfront.

Knowing what treatments or procedures a patient will need allows provider staff to gather the proper authorizations before treatment. Preparation can help ensure the billing statement is accurate and reduce the likelihood of claim denial later. Also confirming the patient is insured and their information is up-to-date and accurate can further prevent claim denials.

Prioritization for Services

With eligibility checks done, physicians can know what services they can provide. Administrators can discuss options with the patient upfront. This discussion helps patients understand their financial responsibility going into a procedure so they can determine the best course of action.

Cost-Effective Care for Patients

Understanding costs upfront can reduce headaches later for patients later, eliminating “surprise” medical bills. It can make a significant impact on the patient’s experience. Discussing patient options for treatments and procedures alongside insurance coverage will relieve the financial strain on both parties. A clear understanding will also help providers work with patients to develop a course of action and treatment plan.

Clear Understanding of Patient Responsibility

A frank discussion with patients about their financial responsibility can help them understand what will and will not be covered. It can also help identify any coinsurance payments. Upfront copay collection helps improve the revenue cycle. It can also reduce the number of accounts sent to collections because the patient’s insurance and financial responsibility are clear from the start.

Prevent Unnecessary Surprises

No one wants to get an unexpected bill for services. Knowing upfront what costs the patient will be responsible for can remedy this. It also allows patients to seek treatment at a more cost-effective facility that’s in their insurance network if needed. When possible, patients can plan for services to avoid unwanted surprises.

How To Check Health Insurance Eligibility

The medical insurance verification process is relatively simple and doesn’t take long. However, it requires accuracy and diligence to ensure claims are paid during the process and your healthcare facility can collect prompt payment. Check patient insurance eligibility with these steps.

Gather Your Patient’s Insurance Information

Start by collecting the patient’s insurance card to understand their carrier, policy number, and copay and coinsurance information. Be sure to collect demographic details from the patient during this same time, including their full legal name, date of birth, and address.

Use EHR Software for Patient Information

Use an electronic health record (EHR) to store patient data securely. EHR software makes it easy to store information about previous visits, health conditions, procedures, and prescriptions and refer to them in the future. It also holds insurance information, which can easily be updated if the patient’s insurance changes. EHR software can integrate with insurance verification tools to access patients’ medical records, which can improve accuracy and make the process more efficient. This allows providers to check health insurance eligibility online — quickly and securely.

Determine Coverage Details & Patient Responsibility

With the patient’s information in the EHR, medical administrators can electronically check the patient’s eligibility by selecting the benefit and service type. You’ll want to gather the following information during this check:

  • Policyholder
  • Policy effective date
  • Policy term date
  • Patient copay or coinsurance
  • Patient’s deductible and accumulations
  • Patient’s out-of-pocket maximum andaccumulations
  • Pre-authorization for service (if applicable)
  • Patient out-of-network coverage

Get a copy of the patient’s insurance card, even if they say nothing has changed. Keeping an updated copy of both sides of the card ensures the information is current.

Review Requirements for Prior Authorization

Before scheduling services that may need pre-authorization, it's crucial to review the patient's insurance policy requirements. This involves checking if the proposed medical service or procedure requires prior approval from the insurance company to ensure coverage.

Contact the insurance provider to understand the specific criteria for authorization, including necessary documentation and time frames. This step is essential to prevent claim rejections and ensure the patient receives timely and covered healthcare services. Educating the patient about the importance of prior authorization can also help streamline the process.

Communicate Clearly with the Patient

Transparently explain the process to the patient so they understand what to expect next. Once you know their financial responsibility, communicate this so they understand when and how to pay on time. This helps the patient know what to expect and what information to provide.

Commence Prior Authorization (If Needed)

If the review process confirms that prior authorization is necessary, initiate the process without delay. Start by gathering all required documentation, including medical records, treatment plans, and any other supporting evidence. Submit these documents to the insurance provider, following their specific guidelines and procedures.

Keep the patient informed throughout this process, as their timely cooperation may be needed. Prompt and accurate submission of the authorization request is crucial to avoid delays in the patient's care and ensure that the services are covered by their insurance plan.

Health Insurance Eligibility Checklist

To ensure insurance verification is done correctly, office staff should enter the insurance information as it appears on the card and complete insurance verification through the proper channels. Here’s a checklist of what to look for in eligibility verification:

  • Insurance company name
  • Insurance company phone number and address
  • ID and group number
  • Name of insured party (this isn’t always thepatient)
  • Relationship between patient and insured party
  • Policy effective date
  • Policy end date
  • Confirm coverage is active


With those details secured, the next step is to verify details specific to the facility and the patient’s treatment, including:

  • Confirm insurance covers the procedure orservices to be provided
  • Confirm the medical facility accepts theinsurance policy
  • Policy limitations
  • Referral information
  • Patient copay and deductible amounts

Health Insurance Eligibility Check: Automatic vs. Manual

Providers can verify patient eligibility manually by calling the patient’s insurance company. They’ll speak to an insurance representative, who then checks their system to confirm the patient’s coverage and benefits. While this sounds like a relatively smooth process, reaching the insurance company by phone can be time-consuming and typically requires time on hold.

The quicker alternative is going through an automated system to check insurance eligibility electronically. These systems can be integrated with EHR sand can complete verification quickly by scanning insurance carrier databases electronically. These computerized systems can also provide information on patient copays, deductibles, and out-of-pocket costs. This method is typically faster than the manual process, making it easier for all parties involved.

How Can Office Ally Help With Checking Insurance Eligibility

Eligibility and Benefits tools provided by Office Ally can help providers reduce claims rejections and improve patient satisfaction. You can easily decrease AR days and bad debt risk by verifying patient eligibility and benefits before or at intake, minimizing rejected claims and improving collections. With direct data entry you can streamlined workflows and access to hundreds of payers through our multi-payer portal to help improve efficiency and staff members’ productivity. Learn more about Office Ally’s suite of products with customizable features to aid with healthcare revenue cycle management.