Always Step #1: Doing a Benefit Verification

What is Benefit Verification?

A benefit verification involves contacting a patient's medical insurance provider (using the number found on their website or on the back of their insurance card) to gather essential details about the patient's coverage.

What Information Do I Need to Complete a Benefit Verification?

To perform a benefit verification, you'll typically need:

• The patient's full name, date of birth, and address.
• The front and back of the patient’s medical insurance card, including the Member ID and Group/Policy number.
  
  Tip: When calling on behalf of a provider, be sure to have the provider's NPI, Tax ID, and the name of the provider or facility ready. This will ensure that you can connect with a representative quickly and efficiently.

What Information Will I Receive from the Insurance Company?

When you reach out to the insurer, you can expect to receive the following details:

• Confirmation of Active Coverage: Verifying that the patient has an active policy with the insurance company.

• Deductible Status: Information on the patient's annual deductible—how much they have paid so far and how much remains.
  For example: If a patient has a $3,000 deductible and has already paid $2,000, they will still owe $1,000 before their insurance kicks in to cover medical treatments.

• Co-Insurance Information: After the deductible is met, insurance typically covers a certain percentage of the cost, and the patient is responsible for the rest. This can vary, for example:
  70% insurance / 30% patient, 80% insurance / 20% patient, 90% insurance / 10% patient, or potentially 100% coverage once the deductible is met.

• Out-of-Pocket Maximum (OOP): The maximum amount the patient will pay out-of-pocket, both for in-network and out-of-network providers, on a yearly basis.
  For example: If the OOP max is $4,500, once the patient reaches that amount, insurance will cover 100% of the costs for the rest of the year.

• Prior Authorization: Prior authorization is a process in which your insurance company must approve a service, treatment, or prescription before it can be provided. During the benefits verification, your insurer will inform you if prior authorization is required for any specific services and guide you on how to obtain the necessary approval.
•  Gap Exception: A gap exception is a valuable option offered by health insurance companies to bridge gaps in their network of contracted providers. If approved, this exception allows you to receive care from an out-of-network provider while paying the lower in-network cost-sharing fees, typically on a one-time basis. During the benefits verification process, your insurer will inform you if a gap exception is available under your policy and provide instructions on how to request it.

What does an example of a benefits break-down look like?