Eligibility Verification

You Find Out a Claim
Was Denied. We Find Out
Before the Patient Arrives.

Insurance eligibility failures cause 23% of all denied claims. Every one of them was preventable. ProvidaRCM runs a complete 6-point verification on every patient 24 to 48 hours before every appointment , so you bill correctly the first time, every time.

Get Free Eligibility Audit → How It Works ↓
Patient Eligibility Verification
MK
Michael K. Torres  ·  DOB 11/03/1968
Aetna Choice POS II  ·  Member ID: AET4429017
Coverage Status
Active
In-Network Provider
Confirmed
Deductible Remaining
$1,480 of $2,500
Specialist Copay
$50 per visit
Prior Auth , CPT 27447
Required , Initiating
Secondary Insurance
None detected
Collect $50 copay at check-in. Auth request initiated for CPT 27447. $1,480 deductible outstanding , patient owes 20% of balance after copay.
23%
Denials From Eligibility
Largest single denial category
91%
Preventable With Verification
Before the service is rendered
48h
Before Every Appointment
Standard verification window
100%
Patients Checked
No sampling, no exceptions

What Happens When You Skip the Check

Without pre-appointment verification, your team finds out about coverage problems after the claim is denied , too late to prevent the revenue loss.

These are the five most common eligibility failures we catch before they become denied claims. Each one represents money your practice would have written off without ProvidaRCM running verification first.

23%
Insurance Terminated Without Notice
Patient changed employers three months ago. New plan was never collected. Old plan is terminated. Claim filed to inactive coverage , denied on day 1. Recovery takes 45+ days with a 48% success rate.
Most Common
$840
Wrong Plan Billed as Primary
Patient has a secondary Medicare plan that is actually primary. COB order was never confirmed. Claim filed to wrong payer , denied. Requires re-billing in correct sequence and delays payment by 30+ days.
COB Error
19%
Auth Required, Not Obtained
Procedure required prior authorization. No one checked at scheduling. Service rendered without approval. Claim denied , retroactive auth attempt has less than 50% success rate.
Authorization
$0
Referral Not in File
HMO patient needs a referral from their PCP before the specialist visit is covered. Referral was never requested. Patient seen, claim submitted, claim denied. Patient billing dispute follows.
HMO Failure
2×
Wrong Copay Collected
Front desk assumed same copay as last year. Patient's plan changed. Actual copay is $55, collected $30. Patient receives a surprise balance bill. Dispute filed. Collections cost more than the $25 difference.
Collection Error
48%
Recovery Rate After Denial
When eligibility denials do occur without verification, fewer than half are ever fully recovered. The average appeal takes 6 weeks of staff time. Most practices ultimately write off the remaining 52%.
Write-Off Risk

Five Steps. Every Patient. Every Day.

Our verification workflow runs automatically on every scheduled appointment , pulling your schedule, querying every payer in real time, and delivering a complete report to your front desk before the patient arrives.

1
Schedule Pulled From Your EHR
›
We pull tomorrow's complete appointment schedule from your EHR or practice management system 24 to 48 hours in advance. No manual input from your team , the process runs automatically through our secure system integration.
All major EHR platformsAutomated daily pullSecure integration
2
Real-Time Payer Query , Every Patient
›
We submit a live 270/271 eligibility transaction to each patient's insurer through our clearinghouse connections. This is not a cached lookup , it is a real-time query that returns current coverage status, benefit detail, and any changes that occurred since the patient's last visit.
270/271 real-time transactionAll major payersZero caching
3
Six-Point Benefit Extraction
›
We extract all six critical benefit categories from each payer response: active coverage status, deductible and out-of-pocket progress, copay and coinsurance amounts, network status and referral requirements, prior authorization requirements, and secondary insurance with COB order. Every piece of data that affects billing and patient collections.
Coverage active/terminatedDeductible progressExact copay amountAuth requirementsCOB order
4
Issues Flagged, Auth Initiated
›
Any coverage issue , terminated plan, COB conflict, referral requirement, auth requirement , is immediately flagged with a clear recommended action. Auth requirements are escalated to our Prior Authorization team the same day so approval is in hand before the appointment date.
Clear action itemsAuth escalated same dayPatient contact prompts
5
Complete Report Delivered to Your Team
›
A complete, patient-by-patient verification summary is delivered to your front desk before the appointment day. Issues are highlighted clearly. Copay amounts are listed for every patient. Your team arrives knowing exactly what to collect and which patients need to be contacted , before anyone walks through the door.
Pushed to your systemEmail summaryWeb dashboardIssues highlighted
Verification Report , Tomorrow
Patient , Robert K. Davies · Appt 9:00 AM
Coverage
Active
Network
In-Network
Deductible Remaining
$850 of $2,000
Specialist Copay
$55
Coinsurance
20% after ded.
Secondary
None
Collect $55 copay. $850 deductible remaining , patient owes 20% after copay.
Patient , Amanda S. Chen · Appt 10:30 AM
Coverage
Plan Change
Network
Verify New Plan
Previous plan terminated. Contact patient before appointment to collect updated insurance details.

Six Things We Verify. Zero Left to Chance.

A real eligibility check is not just confirming insurance is active. It is six separate verifications that together determine whether a claim will be paid , before you ever perform the service.

Active Coverage
Real-time confirmation the policy is active on the appointment date. Catches the #1 eligibility failure , plan terminations and employer changes that happened since the patient's last visit.
Policy effective and termination dates
Member status , active, terminated, suspended
Plan year and renewal date
01
Deductible and Out-of-Pocket
Current deductible amount and how much has been met year-to-date. This determines what the patient owes at check-in and how the claim processes after submission.
Individual and family deductible progress
Out-of-pocket maximum and amount met
In-network vs. out-of-network separate amounts
02
Copay and Coinsurance
The exact cost-sharing amounts for this specific visit type. PCP, specialist, preventive, and urgent care each carry different amounts. We report the one that applies to this appointment so the right amount is collected at check-in.
PCP and specialist copay amounts
Coinsurance percentage after deductible
Preventive visit specific coverage
03
Network Status and Referrals
Your provider and facility are confirmed in-network with the patient's current plan. Network lists change without notice , and HMO plans require referrals from a PCP that must be in hand before the visit is covered.
Rendering provider current network status
Facility location network confirmation
PCP referral requirement for HMO plans
04
Prior Authorization Requirements
Which procedures on today's schedule need prior authorization? We identify auth requirements during verification and immediately escalate to our Prior Authorization team so approval is obtained before the service date , not the day of.
CPT-level auth check per payer
Auth initiation triggered same day
Existing auth numbers validated
05
Secondary Insurance and COB
Secondary coverage identified and Coordination of Benefits order confirmed. COB errors , billing the wrong plan as primary , are a significant and frequently overlooked source of eligibility denials, especially for Medicare patients.
Secondary insurance identification
Primary vs. secondary billing order
Medicare Secondary Payer compliance
06
Before ProvidaRCM
What Your Practice
Looks Like Without
Verification
Revenue leaking to preventable denials. Front desk spending 2+ hours daily on hold. Staff chasing coverage problems discovered only after claims are rejected. A 48% recovery rate on the denials you do catch.
23%
of claims denied from eligibility errors , the largest single denial category in your practice
48%
average recovery rate once an eligibility denial is filed , the rest is written off permanently
2h
per day your front desk spends on manual insurance calls that ProvidaRCM eliminates entirely
With ProvidaRCM
What Changes in the First 60 Days
Eligibility denials eliminated before they happen. Front desk works from a complete verified report. Correct copays collected every visit. Authorization requirements caught and approved before service.
91%
reduction in eligibility-related claim denials , visible within the first 30 to 60 days
$18K
average monthly revenue recovered per 400-appointment practice from eliminated eligibility denials
97%
average first-pass claim acceptance rate after 60 days , up from the low to mid-80s
Get Free Eligibility Audit →
We review your last 90 days and show you exactly what eligibility is costing you.

Eligibility Verification Works Best as Part of Complete RCM

Front-end verification eliminates the largest denial category. Pair it with the services below for a fully protected revenue cycle.

Medical Billing
Full-cycle billing from charge capture through payment posting and reconciliation.
Learn more
Prior Authorization
Auth requirements flagged during verification are approved before the appointment.
Learn more
Denial Management
Denials that do occur are appealed aggressively with an 87% reversal rate.
Learn more
Medical Credentialing
Confirms in-network status with every payer so verification results are always accurate.
Learn more