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The Complete Checklist for Eligibility and Benefits Checks

Main Points

  • Getting benefit information is important for the success of your practice

  • Create a standard eligibility and benefits check template for your staff

  • Step-by-step eligibility process


Getting accurate eligibility and benefit information over the phone is critical for your revenue cycle management process, and can either greatly benefit your practice or harm your patient experience.

This is further complicated by the complicated processes and procedures for getting benefit information. Questions begin to arise such as;

  • What is a carve out insurance (more to come on this)?

  • What is the patient's deductible?

  • How do I calculate a coinsurance?

  • What number do I call?

  • What codes are covered?


To help with this problem we have created THE comprehensive checklist of how to conduct an eligibility and benefits check for you, your admin, or your biller. This process will help you ensure that you have all the information necessary before seeing a patient, and will help your patients have a great experience when they come into your practice for services.

Pro-tip: Create a standard eligibility template that your practice can use over and over. A fillable template is preferred so you always obtain the same information no matter who calls the insurance company


Here is the process for getting benefits over the phone

  1. Call the number on the back of the card

  2. Have your NPI, Tax ID ready

  3. Have the patient DOB, Name, Insurance ID, and sometimes address ready for the rep

  4. Follow the instructions for the automated system

  5. Find a way to a person as quickly as possible

  6. REMEMBER: They are on your time, not the other way around. Don’t let them rush you!

  7. Get all the information on the eligibility and benefit check form

  8. Clarify the information as needed

  9. Obtain a reference number and index this number

  10. Calculate the patient responsibility A coinsurance is just a percentage of your contracted rate. For example, if your contracted or allowable rate is $100.00 and your patient has a 20% coinsurance, then they would pay you $20.00 at the time of service.


If you have any questions about eligibility and benefits checks feel free to contact us by filling out our contact form and a member of our team would be happy to talk to you!

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