Verification of eligibility stands out as one of the most important steps for both Medicare and Medicaid in the claims processes. Confirmation of patients' eligibility helps proactively mitigate provider errors, denial reduction, reimbursement smoothing, provider error mitigations, streamlining seamless payment processing. This article focuses on examining how to undertake eligibility verification for both programs in detail.
Step 1: Obtain Patient Information
To begin, gather the necessary information of the patient such as full name, date of birth, insurance info, and for Medicare cases collecting medicare number while for medicaid cases gathering medicaid id along with relevant demographic info is a must.
Step 2: Use Online Portals for Verification
For Medicare, you can use the Medicare Administrative Contractor (MAC) Portal or access the Eligibility Transaction System (ETS) to verify patient eligibility. For Medicaid, each state has its own eligibility system, which you can access through state-specific portals or eligibility verification tools.
Step 3: Review Coverage Details
After entering the patient’s information, the system will specify eligibility information concerning coverage for Part A, Part B, and, if relevant, Part C or D (Medicare), or the services covered under the state’s Medicaid plan. Also look for any applicable secondary insurance details.
Step 4: Confirm Service Coverage
Confirm that the services you intend to offer are included in the patient’s Medicare or Medicaid plan coverage. Some services may need prior authorizations or have limitations specific to the service type.
Step 5: Document Verification Details
Document the verification outcomes with details about the date of verification, status of coverage, and additional information such as co-pays, deductibles, or any applicable limitations. Precise record keeping will aid in avoiding claim denials and ensure precision during future billing..
Why Eligibility Verification Matters
Confirming a patient’s coverage for both Medicare and Medicaid aids in streamlining administrative expenses as well as Providing clarity for both patients and healthcare patients regarding the boundaries set by the insurance policy. Moreover, it mitigates the chances of payment postponements or claim rejections owing to eligibility problems.
How Mastermind Healthcare Can Assist
At Mastermind Healthcare, we offer comprehensive revenue cycle management services, including eligibility verification. Our team ensures that your claims are processed smoothly by confirming patient eligibility, checking coverage, and ensuring proper documentation before submission. This helps minimize denials and optimize reimbursement rates.
Posted on April 16, 2025 | By Mastermind Healthcare RCM Tactics