Verifying Eligibility and Effective Dates
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 file. You must coordinate initiation of electronic eligibility files with your software vendor and us. Advantages of receiving electronic eligibility are:
- Lower cost and effort required to maintain eligibility manually.
- Faster updates loaded into your system.
Refer to ASC X12 Technical Report Type 3/ Companion Guides for more information. Or ask your provider advocate.