Verifying Eligibility and Effective Dates, Capitation and/or Delegation
For information on ways to verify eligibility, please refer to ‘Verifying Eligibility, Benefits, and Your Network Participation Status’ in Chapter 2: Provider Responsibilities and Standards. This helps ensure you:
- Submit the claim to the correct payer
- Collect copayments
- Determine if a referral, prior authorization or notification is required
- Reduce denials for non-coverage
We can provide you with daily and/or monthly member eligibility information using an electronic 834 file containing eligibility changes. You must coordinate initiation of electronic eligibility files with your software vendor and us. Some of the advantages of receiving electronic eligibility are:
- An eligibility upload may reduce your costs by reducing the effort required to maintain eligibility manually.
- Eligibility updates may be loaded into your system in a timely manner.
Refer to the section titled ASC X12 Technical Report Type 3/Companion Guides for more information, or ask your provider advocate.