How to Verify Health Insurance

Verifying Health Insurance as a Health Care Provider

Maintain accurate records. Make sure that patient information is up-to-date. The basic information you should have in the record are patient's name, and date of birth, the name of the person who is the primary insured (commonly the mother’s or father’s name if your patient is a child), social security number, the name and contact information of the insurance provider, and the patient’s insurance ID and group number. If you do not have the information required by the insurance company, and if this information is not accurate, you may not be able to verify the patient’s insurance. Many factors regarding insurance coverage can change over a short period of time. Things like birth or adoption of a child, marriage, divorce can affect coverage.

Request photo ID and the original health insurance card from the patient. Make copies to place in the paper file or scan for electronic filing.

Contact the insurance provider through phone or computer based system to confirm coverage for the patient. A toll-free number is generally noted on the back of the insurance card, along with other relevant contact information for the health insurance company.

Find out whether or not the patient will be covered on the date of service. If your patient has an appointment in the future, it is important to clarify whether or not his insurance will be valid on that date. You can verify this with the insurance company.

Clarify the benefit options with the insurance company. Your patient will likely have a co-pay and may have certain services which are covered and some that are not. Clarify this with the insurance company. If there are certain services your patient requires that are not covered by his insurance, make sure the patient understands this.

Verify whether the patient is in- or out-of-network. This refers to whether you, as a healthcare provider, are an in-network health care provider or out-of-network health care provider. If you are not in the patient’s network, the patient’s insurance may not cover all or any of any services you render.

Find out how much the patient’s deductible is. A deductible refers to a set amount of health care costs that a patient must pay before the insurance will begin to pay. The amount varies, so be sure to verify this amount with the provider. Also be sure to verify whether or not the amount has already been met from other visits (perhaps with other doctors).

Obtain verification of co-pay. Collect any co-pay that is due from the patient, and provide them with a receipt. The receipt should outline the services provided and the costs so that the patient can verify their own health insurance.

Be prepared to answer patient inquiries about co-pays and coverage. If necessary, contact the insurance provider to verify those items that you are uncertain of, particularly if insurance is new to the patient.

Ask the patient if they have a secondary insurance. Verification of secondary insurance would include the same steps as mentioned for primary insurance. Verify specific percentages or amounts covered by the secondary provider.

Verifying Your Own Health Insurance

Maintain detailed health care records. It is important that you have a record of the treatments you received and when. You can do this by keeping a file in a filing cabinet, or you can keep a digital record, for example in an Excel sheet. Either way, you should have detailed information listing amounts paid, purpose of visit, surgeries, preventative care (such as dental cleaning), etc. If you are missing information, you can request the missing information from your doctor.

Keep your health insurance provider informed of any life events. Certain life events may affect your coverage. Therefore, it is important to keep them updated on certain events (e.g if you get married, have a baby, adopt a child). If the insurance does not have accurate records, and later finds out that you failed to inform them, they may refuse to pay for your medical care. You may also end up paying more than you need to.

Read the information you received from your health insurance provider carefully. When you enrolled in your health insurance plan, you probably received a packet of information describing your plan, what it covers, what it doesn’t, how much your deductible is, etc. Read this thoroughly so that you understand the details of your coverage.

Arrange an appointment with a representative of your insurance provider. If there is anything you do not understand, or want clarification on, schedule an appointment with a representative. This way, the representative will have adequate time to explain, clarify, and answer any questions you have about your coverage.

Call your insurance company. Before scheduling major procedures, it is a good idea to give your provider a call. Make sure that there are no problems with your insurance and that no additional information is needed. Find out if and how much of the cost of your procedure will be covered. By doing this, you won’t have an ugly surprises once your procedure is completed.