Description
Verify insurance eligibility, benefits, and authorizations; validate policyholder information; review policies to determine coverage; resolve discrepancies with carriers; document findings, update systems, and communicate coverage requirements and estimated responsibility to patients, providers, and billing teams.
- • Verify member eligibility, plan status, and effective dates with carriers.
- • Review insurance policies to determine covered services, exclusions, and limits.
- • Confirm demographic data, member IDs, and group numbers for accuracy.
- • Document benefits, deductibles, copays, coinsurance, and out-of-pocket balances.
- • Obtain and track prior authorizations and referrals as required.
- • Review clinical or service details to support authorization requests.
- • Submit verification and authorization requests via payer portals, EDI, or phone.
- • Follow up on pending or denied authorizations and escalate as needed.
- • Communicate coverage and authorization status to patients, providers, and billing.
- • Provide estimates of patient financial responsibility based on verified benefits.
- • Resolve discrepancies in coordination of benefits and primary or secondary payer.
- • Update practice management, EHR, and billing systems with verification results.
- • Attach verification records and authorization numbers to patient accounts.
- • Prepare, process, and file verification forms and correspondence.
- • Maintain detailed logs and reports of daily verifications and outcomes.
- • Contact insurers or members to obtain missing or corrected information.
- • Re-verify benefits on the day of service or when schedules change.
- • Identify network status and participating providers for planned services.
- • Verify special program coverage, such as Medicare, Medicaid, workers' comp, or auto.
- • Notify scheduling and clinical teams when coverage is inactive or insufficient.
- • Ensure claims include required authorization and referral information.
- • Adhere to HIPAA and payer compliance rules and documentation standards.
- • Educate patients on coverage requirements and next steps.
- • Maintain current knowledge of payer policies and portal procedures.
- • Enter accurate notes and codes to support clean billing and timely payment.
- • Generate and distribute alerts for denials or expiring authorizations.
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O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
