Eligibility, benefits and prior authorization
Know coverage and authorization status before the patient arrives
Eligibility verification confirms that a patient's plan is active and identifies their benefits — copay, deductible, coinsurance, visit limits and whether authorization is required. Prior authorization is the payer's advance approval for certain services. Verification reduces surprises; it is not a guarantee that a payer will pay the claim.
Does this sound familiar?
- Claims deny for inactive coverage that could have been caught at scheduling.
- Authorizations expire mid-treatment or run out of approved visits.
- Patients are surprised by deductibles and stop coming.
- Front desk staff spend hours on hold with payers.
Scope of work
Exactly what this service covers — and what it doesn't — so responsibilities are clear before you sign anything.
Included
- Eligibility and benefits verification ahead of scheduled visits
- Benefit summaries for your front desk: copay, deductible, coinsurance, visit limits
- Identification of services that require prior authorization by payer
- Authorization request preparation and submission with your clinical documentation
- Authorization tracking: approved units/visits, date ranges and renewal reminders
- Re-verification for recurring patients on a set schedule
Not included
- Guarantee of coverage or payment — payers make final determinations at adjudication
- Clinical decisions about medical necessity
- Patient financial counseling beyond explaining verified benefits
How the work flows
- 01
Schedule pulled
Upcoming appointments are pulled on an agreed lead time.
- 02
Verify
Coverage and benefits are checked electronically (270/271) or by portal/phone.
- 03
Flag
Inactive coverage, missing authorizations and exhausted visits are flagged to your team.
- 04
Authorize
Requests are submitted with documentation and tracked to decision.
- 05
Track
Approved visits are counted down so renewals start before they run out.
What we measure
Measured against your own baseline. We don't quote benchmarks or other clients' results.
- Verification coverage
- Share of scheduled visits verified before the date of service.
- Eligibility-related denials
- Denials for coverage or eligibility reasons as a share of claims.
- Authorization-related denials
- Denials for missing or expired authorization.
What we need from your practice
- Schedule access with enough lead time
- Payer portal access
- Clinical documentation for authorization requests
- Patient information is exchanged only through secure access you control — never through forms or email on this website.
Eligibility, benefits and prior authorization: common questions
If you verify eligibility, will the claim definitely be paid?
No. Verification reflects what the payer reports at that moment. Payers make final decisions when the claim is processed, and coverage can change. Verification significantly reduces avoidable surprises; it does not remove payer discretion.
How far ahead do you verify?
We agree a lead time with you — commonly a few business days before the visit, with same-day checks for new patients where your schedule allows.
Related services
- Denial prevention and appealsFront-end checks, denial categorization, appeals and trend reporting to stop repeat denials.
- End-to-end medical billingCharge entry through payment — claims built, scrubbed, submitted and followed until resolved.
- Patient billing helpdeskPatients get clear answers about statements and balances — no clinical advice, ever.
Content last reviewed . Payer rules change; this page is general information, not legal or coding advice for a specific claim.
Talk to us about eligibility, benefits and prior authorization
Tell us where payments are getting stuck. In 20 to 30 minutes we'll show you what we'd check first, and tell you plainly if we can help.
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