How Insurance Eligibility Verification Works

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How Does Insurance Eligibility Verifications and Pre-Authorizations Work

How Does Insurance Eligibility Verifications and Pre-Authorizations Work?

Most claim denials are due to not properly verifying benefit information prior to services being provided. Insurance eligibility verification and prior authorization is the first and vital step in the medical billing process. Insurance verification process is crucial for all encounters, whether inpatient, outpatient or ambulatory care.

It will ensure that the hospital/medical office receives payment for services rendered and will help determine the patient’s share of the hospital’s charges referred to as the patient’s responsibility. Eligibility verification is the process of checking a patient’s active coverage with the insurance company and verifying the authenticity of his or her claims.

To avoid claim rejection, the verification process must be done before the patient is admitted into a hospital, sees a physician or gets services from a medical professional.

Coverage and eligibility benefits should be verified for


all new patients


hospital admissions


any patient who indicates a change to their coverage, and


for all high dollar procedures

Pre-authorization is required for many non-emergency medical procedures and services. Caught between practice administration and patient care, many physicians find it difficult to complete such important tasks on time.

Outsource Strategies International (OSI) can assist physicians and healthcare practices with their insurance eligibility verifications and pre-authorizations.

Our health insurance eligibility verification services are meant to help you


minimize rejections and denials and


improve bad debt write-off scores


reduce coverage errors

Knowledgeable in each and every aspect of health insurance, healthcare terminologies and medical/surgical techniques, our verification specialists work with payers as well as patients to verify eligibility and obtain authorizations for services or procedures to be provided.

Insurance Eligibility Verification – Step by Step Process


Receiving patient demographic information from referral sources such as hospital or clinic or from the patient directly.


Verifying patient information with the carrier. This service includes verification of:

  • payable benefits
  • co-pays
  • co-insurances
  • deductibles
  • patient policy status
  • effective date
  • type of plan and coverage details
  • plan exclusions
  • specific coverage
  • claims mailing address
  • referrals and pre-authorizations
  • life time maximum

Verifying patients’ coverage on all primary and secondary payers


Updating patient accounts


Communicating with patients and completing paperwork

Precertification Process


Obtaining pre-certification number when it is needed for a procedure, visit or other treatments


Completing appropriate criteria sheets and forms


Contacting the insurance companies on the physician’s behalf to obtain approval for your authorization request


Once the forms are filed either online or via a web portal, then the specialist will follow up until authorization is received


If any further documents are necessary, we will make arrangements to get those

Our specialists can also communicate with companies for appeals, missing information and other details to ensure accurate insurance billing. Once the verification process is over, the authorization is obtained from insurance companies via telephone call, facsimile or online program.

Why Are We Good at What We Do?

With our services, you can free up your staff’s time from waiting on hold with insurance companies.
  • We work directly in your software or out
  • We work to stay ahead of your schedule and the verifications are done before the patient comes into the office
  • Our cost is lower than hiring an in-house verification team and you are getting an experienced person to work for you
  • Our team can identify when a prior authorization is needed and thus prevent denials for services provided.
  • Our QA team ensures that we meet 98% accuracy.  We also record the phone calls with the insurance representatives for QA purposes.

No need to train employees on software.  Hiring an employee through us saves you money on taxes and other staff benefits.

Knowing patients’ dental or medical coverage can help you plan custom treatments and identify non-covered services. Our team is also experienced in providing dental eligibility verification services for dental care providers.