Verifying Patient Insurance

in this lesson we'll review the process of verifying a patient's private health insurance benefits after completing this lesson you'll be able to explain why it's important to verify insurance describe how to verify a patient's private insurance coverage and explain the difference between primary and secondary coverage when a patient comes to your local health department clinic with a health insurance card it does not mean he is currently eligible or covered common reasons insurance may not be

valid include the person's employer may have changed health plans or health insurance carriers making the old plan and card obsolete in addition some employees have month-to-month eligibility depending on how many hours they have worked an insurance policy may be terminated if the subscriber left his job if the person is uninsured due to a life change like loss of job you can also refer them to medical or covered California to seek health insurance because changes can occur at any time

you want to verify a patient's eligibility status every time sometimes people are covered by more than one plan such as when a spouse has coverage or when a child is covered by both parents if a client presents two insurance cards you will need to determine which one is primary the primary insurance is the one you will bill first the subscriber meaning an individual's own health plan coverage is the primary insurance in the case of an adult who has dual coverage

from a spouse the spouses insurance would be secondary in the case of a child covered by two separate insurance plans say one from each parent the parent whose birthday falls closest to January 1st becomes the primary insurance this is called the birthday rule for the dependents of the plan limited exceptions apply now let's review the insurance verification process you can follow along now and at your convenience download the job aid on verifying

private insurance as a handy reference let's say a patient comes into the clinic and you know that you're not an in-network or preferred provider you can follow these steps to get the most current information on his insurance coverage first call the customer service number on the patient's health plan ID card ask if they have out of network benefits for the service the patient is seeking if not you will not be able to build the health plan some clinics offer a sliding scale if the patient can pay

out of pocket be sure to check whether the patient has met his annual deductible specifically for out-of-network services or if coinsurance is due if the patient is eligible for out-of-network services you'll be responsible for letting him know the amount of deductible needed if it's not yet met for the year and the amount of any applicable coinsurance with immunization services most private insurance companies cover the cost of routine immunizations given by both

in-network and out-of-network providers there are two methods you can use to verify a patient's up-to-date insurance status we'll run through the pros and cons for each method for your convenience you can reference the downloadable job aid private insurance calling vers online verification when you're ready to get started first we'll look at online insurance verification most private insurers have their own website where you can go to verify a patient's coverage going online is

typically faster than making a phone call and you have the benefit of downloading or saving a document that can be attached to a patient file some of the drawbacks are that the out-of-network benefits may not be clear if they are listed at all also it may not show whether or not the patient has met their deductible using the customer service line to call is a second option for verifying a patient's insurance coverage some of the benefits are that you can speak to a live person who can answer specific coverage questions the

rep will be able to tell you about the out-of-network coverage for the service the patient has come in for and can look up the status of the patient's deductible to see if this has been met remember there may be separate deductibles for in-network and out-of-network services the one drawback to verify insurance information by phone is that it can be very time-consuming whenever you contact a patient's insurance company be sure to document the information you receive this includes remembering to ask for the reference or tracking number and the

name of the representative you speak with then you can note any relevant information about the patient's benefits and insurance status the downloadable job aid sample insurance status log sheet will give you a sample log that you can adapt for your own needs it's a designated place to record all the information from your phone conversation now please follow the instructions to take the quiz for this lesson it will look familiar it's the same one you took before viewing the lesson this time

you'll be able to see the correct answers as you respond to demonstrate what you've learned after you've completed the quiz you may continue at your own pace to view subsequent lessons at your convenience the lessons are ordered so you'll build your knowledge of each part of the billing process that relates to your role when you finish all the lessons you'll be able to print out a certificate of completion to reward your efforts thanks for your attention please continue on to the quiz