Beyond 'Active' or 'Inactive': The 5 Required Questions for a Clean Eligibility & Benefit Check Every Time

You just want to get paid for your incredible clinical work, but the insurance company seems to make the process impossible. You call a payer, verify that the patient's coverage is "active" (yes!), and submit the claim, only to have it come back months later as a dead-on-arrival (DOA) denial.

The E&B (Eligibility and Benefits) check should never be skipped, but simply confirming coverage is "active" is not enough. This crucial step is not a simple light switch, and relying on just the active status means walking blind right into more denials and increased headaches.

We’re going to lay out the essential, sequential checklist you need to execute for a thorough verification. By asking these five key questions, you can drastically cut down your denial rate and eliminate costly billing surprises. This process ensures you have the best fighting chance of getting paid for the value you add.

The 5 Eligibility & Benefit Questions

1. Foundational Step: Get the Core Data Right (The Prerequisite)

The first step in this sequential checklist is always getting the core data correct. You have to collect and confirm all the patient’s information: their full name, date of birth, and their subscriber ID.

Think about your intake process here: you need a script that ensures you collect enough information on the phone to get started with the eligibility and benefit check.

Pro-Tip: I can’t emphasize this enough—one of the best things you could do is get a copy of the insurance card, front and back, and get a copy of their driver’s license. This is essential because you need objective sources of truth to move through this process effectively.

2. Question 1: Is the Provider Match Correct?

The primary goal of your eligibility check is twofold: first, to confirm that a patient is eligible for services with you, the specific provider.

The Check: Does the policy cover the rendering provider’s NPI (National Provider Identifier)?.

The Risk of Skipping: Failure to check this can lead to a major denial: "services not covered, this provider is not in network with this plan". When you’re talking to the payer rep or using the portal, make sure you can describe your specialty and your service clearly.

3. Question 2: Are the Specific Services Covered?

Second, and this is the most important part, you need to confirm that you will likely be paid for the service you provide.

The Check: Do they cover the specific CPT code(s) you plan to bill?. You need to list out all the CPT codes for the service your practice provides. You’ll use this list to verify if a patient’s specific plan actually covers the specific service you’re providing. Don't assume, especially if you offer niche services or specialized groups.

The Risk of Skipping: You risk a "services not covered" denial, which can happen if the CPT code isn’t listed on your fee schedule or if the payer uses a subcontractor, or "carve out," for those specific services.

4. Question 3: Are Telehealth/Virtual Services Covered? (And for How Long?)

Telehealth is still a moving target, and you need to confirm all modality requirements.

The Check: Do they cover telehealth services and for how long?. Do they need to have an in-person appointment every six months or so?.

The Risk of Skipping: Failure to confirm these details puts you at a substantial disadvantage to getting paid.

5. Question 4: Is Prior Authorization or a Referral Required?

The Check: Are there any prior authorization requirements?

The Risk of Skipping: If you don't know the prior authorization requirements, your claim is DOA—dead on arrival. Dealing with these types of denials can create major administrative follow-up headaches. We'll be tackling this major headache in our next episode of The Claim Game, so you won't want to miss that.

6. Question 5: What are the Financial Details? (The Deductible Breakdown)

While confirming coverage is primary, these financial details are essential for setting expectations with your client.

The Check: Gather the deductible, the copay, coinsurance, and out-of-pocket max, and confirm if they have an individual and family plan. You also need to confirm if they have a primary and secondary insurance plan, which leads to coordination of benefits.

The Risk of Skipping: If you don't collect this information, you won't be able to communicate accurate financial responsibility, leading to patient receivables, which negatively impacts your cash flow.

Your Ultimate Defensive Measure

Once you have this sequential checklist consolidated on a standardized template, the final step is to put it into an easy-to-view location within your electronic health record. This verification is not helpful if it’s not useful—it must drive the patient’s financial balance and claim submission.

For every single eligibility and benefit check you complete, you must secure a date for when you got the check, a rep name if you called, and a reference number.

That paper trail is your "sword and shield". Having these details ensures you can appeal a denial that contradicts what you were told, which is a defensive measure against revenue not coming into your bank account.

You deserve to get paid for the excellent care you provide. Ready to streamline your process? We have a complete E&B check template and an insurance contact reference list available for you with a subscription to the Hourglass Learning Hub.

Check out the resources to get those tools and start recovering your cash today.