Electronic Eligibility Verification Toolkit
How much time and money does your practice devote to verifying patients’ insurance eligibility and policy coverage? How much time does your staff spend on the phone with health insurers and other payers, waiting for responses, and filling out forms? If your answer is “too much,” electronic or electronic data interchange (EDI) health care eligibility requests and responses may be the solution. By adopting this method, your practice can:
- Submit an eligibility benefit inquiry (eligibility requests) and receive payer responses more quickly and accurately
- Identify primary care provider and other medical coverage
- Reduce claims rejections and avoid the collection and billing costs stemming from insurance verification errors
- Determine a patient's financial responsibility from information provided by the electronic eligibility response, to enable your practice to collect from patients at the point of care
- Apply your staff's valuable time and energy to revenue-enhancing activities, instead of spending time making phone calls to health insurers
Cost of handling paper eligibility verification: $3.70 x 1,250 = $4,625
Cost of handling electronic eligibility verification: $0.74 x 1,250 = $925
Average annual savings from electronic eligibility verification per physician: ≈$3,700*
* Based on an annual average of 1,250 verifications submitted for a single physician. Source: Milliman, Inc., “Electronic Transaction Savings Opportunities for Physician Practices.” Technology and Operations Solutions. Revised: Jan. 2006
- Calculate your potential savings using Aetna's EDI savings calculator
What is the purpose of the Accredited Standards Committee (ASC) X12 5010 270/271 health care eligibility benefit inquiry and response transactions (eligibility request and response), and the enhanced patient benefit and financial information being made available by the transactions?
Access an archived webinar, “Electronic eligibility request and response: Much more than ‘Yes, the patient is eligible,” which discusses the use and value of the enhanced eligibility request and response transactions.
- What are the eligibility operating rules, and how do these rules enhance electronic eligibility verification? The Health Insurance Portability and Accountability Act (HIPAA) required all covered entities to support requirements of the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Operating Rules by January 1, 2013. Many health insurers already support the CAQH/CORE Phase I & II Operating Rule requirements. These operating rules enhance the information you receive from an electronic eligibility request. Access “What you need to know about electronic eligibility verification" to learn more about which requirements are included in the HIPAA-mandated operating rules.
- How can your practice use the information from an electronic eligibility response? The HIPAA-mandated Accredited Standards Committee (ASC) X12 270/271 health care eligibility benefit inquiry and response transactions (eligibility request and response) and operating rules will benefit your practice in its effort to collect payment from patients at the point of care. The enhanced standards and operating rules for electronic eligibility verification provide your practice with robust financial information such as copayments, coinsurance, and patient-specific remaining deductible, which can be used to calculate accurate point of care price estimations for patients so that your practice can collect from patients at the time of service.