Patient Benefit Verification Guide

A step-by-step script for those times you absolutely need to call for confirmation of patient insurance benefits.

This guide serves as general questions to ask when verifying patient benefits. At each step, you can enter the appropriate answers directly into StrataEMR.

While this does not guarantee payment or processing, having these details will help with being sure a patient has coverage and benefits applicable to your clinic.

How to verify a patient's insurance benefits.

Once you have reached a live person at an insurance payer on the phone, we recommend the following questions:

  • What is your name? (CSR)
  • Is the provider In-Network or Out-of-Network with this policy?
    • Note: We recommend requesting both for your records if you are unsure of your network status.
  • What is the Effective Date for this policy?
  • Does this policy have co-insurance? (YES/NO)
    • Insurance will cover _______ % (only complete if YES)
    • Patient is responsible for ________% (only complete if YES)
  • Does this policy have a co-pay? (YES/NO)
    • Co-Pay Amount $ _______ (only complete if YES)
  • What is the deductible for this policy?
    • Deductible Amount $ _______
  • How much of the deductible has been met?
    • Deductible Amount Met $ _______
  • What is the Out of Pocket Maximum for this policy?
    • Amount Met $ _______
  • Is this policy a Dual Eligible Plan?
    • Please ONLY select Yes if both the Medicare & Medicaid portion are BOTH handled by this policy.
      • Examples:
        • UHC handles patients MCR & Medicaid and both primary & Secondary claims should be sent to UHC- Select YES
        • UHC handles Medicare claims as a Medicare Replacement Policy but secondary claims go to state medicaid- Select NO
  • Is this policy a Medicare Replacement Plan? (YES/NO)
  • Does this patient's plan have a modality limit (# of units per visit)? (YES/NO)
    • Note: this can be a dollar amount per visit or a unit amount.
  • Does this policy require Authorization? (YES/NO)
    • How should the authorization be obtained? eg, phone, fax, portal (only complete if YES)
    • After what visit is authorization required?
      • This is important. Please be sure to ask this as providers are REQUIRED to upload authorization to us before being able to submit charges.
    • If the CSR indicates Authorization may be dependent on certain CPT codes, the following may be provided as examples:
      • PT: 97110, 97140, 97530, and 97161
      • OT: 97165
      • ST: 92507
  • Does this policy require a PCP referral?
    • Yes, Obtained
    • Yes, Need to Obtain
      • If they do not show a PCP referral on file but one does need to be obtained, please select this option as this will ensure the provider obtains the referral prior to submitting charges.
    • No
  • Does the policy have a Visit Limit? (YES/NO)
    • Is the visit limit structure per calendar year, per quarter or per fiscal year?
    • How many visits have been used? _______ (only complete if YES)
      • This is important as it also contributes to a count that ONLY allows the provider to submit charges UP to the amount of visits.
  • What type of policy is this?
    • PPO, HMO, EPO, Medicaid, Liability, POS, or MCR replacement
  • What specialties do these benefits cover?
    • This is another topic that is rather important as many providers treat for numerous therapies (i.e. Occupational & Physical Therapy) so it is important they know if the patient's 60 visits is for all therapy combined or simply just Physical Therapy.
  • What is the phone number to followup on claims for this policy?
    • Please provide this as it allows StrataPT's AR callers the best and most direct number to follow up on future AR calls.
  • What is the confirmation number for this call?
  • What is the fax number that claims can be sent to?
    • This may not always be available but we always like to ask, as faxing is an additional avenue for sending claims.
  • What is the claim Mailing address?
    • Please obtain this address as it is the final method for claim submission should electronic/fax submission fail.
  • Other Benefit Details (Telehealth, Orthotics, etc)?
    • ie. “Policy terminates on a certain date, or certain things are not covered.
  • Is the policy and demographic information correctly entered for this patient?
    • This provides an opportunity to update any information if, by chance Their ID # was incorrect or the spelling of the patient's name doesn’t match, correcting this information here is important for successful claim submission.

Related:

With millions of data points and over a decade in existence, we know a thing or two about benefits verification. See for yourself:

Recent Reimbursement Rate
99.999975%
Recent Reimbursements Collected
$247,662,601.44
Recent Patients Served
257,491

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