Eligibility and benefits answer different questions
Eligibility concerns whether the patient appears enrolled for the relevant service date. Benefits review concerns how the plan may treat the proposed procedures.
An active policy alone does not establish the amount payable for a specific treatment.
What to check
Relevant items may include:
- Subscriber identifiers and effective dates.
- Network participation and applicable fees.
- Deductibles, coinsurance, and remaining annual benefits.
- Waiting periods, exclusions, frequency or age limitations.
- Alternate benefits, missing-tooth provisions, and orthodontic limits where relevant.
- Documentation, prior authorization, and coordination-of-benefits requirements.
Record the source, date, reference number, and any unanswered questions. Not all information is available electronically or remains unchanged.
Estimate rather than promise
Hypothetical example: A plan appears to offer 80% coverage for a procedure, but a deductible and remaining annual maximum also apply. Quoting 80% of the charge without checking those terms can overstate the expected payment.
Predetermination and authorization are not interchangeable with final adjudication. Explain uncertainty and review the actual claim outcome before determining the final balance.
Manage changes and exceptions
Recheck material changes or conflicting information with the payer. Eligibility can change retroactively, so retain verification evidence and route discrepancies for review.
References: ADA eligibility guidance and ADA discussion of predetermination.