> ## Documentation Index
> Fetch the complete documentation index at: https://mso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Verify eligibility and benefits

> Run 270/271 checks at scheduling and again at check-in, read the response properly, know when to call anyway, and document the check for appeals.

**Eligibility verification** confirms a patient's coverage is active and identifies their cost-sharing before you deliver care. It prevents more denials than any other single control, and the 271 response you save is your evidence when a payer denies anyway.

## Prerequisites

* Eligibility (270/271) enabled through your clearinghouse or EHR
* The patient's insurance card, or the member ID and payer
* A place in the chart to store the response

## The two-check rule

<Steps>
  <Step title="Check at scheduling">
    As soon as the appointment is booked. This gives you days to resolve a problem before the visit, time to call the patient, get corrected information, or reschedule.
  </Step>

  <Step title="Check again at check-in">
    Coverage lapses, plans change at the start of the year, and employment ends. A check run three weeks ago is not evidence of coverage today.
  </Step>
</Steps>

Practices that check once, at scheduling, generate eligibility denials for exactly the population whose coverage changed in between.

## Reading the 271

The response carries more than "active" or "inactive." What to extract:

| Field                                      | Why                                                                 |
| ------------------------------------------ | ------------------------------------------------------------------- |
| **Coverage status on the date of service** | The threshold question                                              |
| **Plan type**                              | HMO, PPO, EPO, POS, affects referral and authorization requirements |
| **Effective and termination dates**        | Confirms coverage spans the service date                            |
| **Deductible: total and remaining**        | Drives the point-of-care estimate                                   |
| **Copay by service type**                  | Often differs from the card                                         |
| **Coinsurance percentage**                 |                                                                     |
| **Out-of-pocket maximum and accumulator**  | A patient who has met it owes nothing                               |
| **Network status**                         | In or out of network for your entity                                |
| **Prior authorization indicators**         | Where the payer reports them                                        |
| **Other coverage / COB**                   | Signals whether you're primary                                      |

**Estimate from the 271, not from the card.** Insurance cards go stale — plans change at the start of the year while the card in the patient's wallet does not. Point-of-care overcollection driven by reading the card is the leading cause of patient credit balances. See [Refunds and credit balances](/concepts/payments/refunds-and-credit-balances).

## When to call anyway

The 271 is not complete. Call the payer or check the portal when:

* **Authorization requirements are unclear** — the 271 often doesn't reliably report them per procedure
* **The service is high-cost**, and you want certainty
* **The plan has a carve-out** — behavioral health, imaging, lab, or pharmacy administered by a different entity
* **The response is ambiguous** or the payer doesn't support real-time 270/271
* **Coordination of benefits looks complicated** — multiple coverages, Medicare secondary, workers' compensation
* **The patient's information doesn't match** the payer's record

## Documenting the check

**Save the 271 response to the encounter.** Not a note saying "eligibility verified." The actual response, with its date and timestamp.

When a payer later denies for eligibility, the saved 271 showing active coverage on the date of service is your strongest appeal evidence. A staff note is not. See [File appeals](/guides/billing/file-appeals).

Also record, for phone verifications: the date, the representative's name, the reference number, and what you were told.

## Batch eligibility

For high-volume practices, run eligibility for tomorrow's entire schedule in one batch each morning, and work only the exceptions. Most clearinghouses support batch 270 submission, and it turns a per-patient task into a 20-minute daily review.

<Note>
  🦴 **PT/Chiro**, also check the **visit authorization count remaining**, not just coverage. Most payers authorize a limited number of visits, and exceeding it without a new authorization is a denial. This is a per-episode tracking problem, not just a per-visit check.
</Note>

<Note>
  🦷 **Dental**, check the **annual maximum remaining**, frequency limitations for the planned service, and any waiting period. A patient with active coverage who has exhausted their annual maximum owes the full amount.
</Note>

## Steps

<Steps>
  <Step title="Enable real-time 270/271 for your payer mix">
    Confirm coverage with your clearinghouse. Not every payer supports real-time; know which don't.
  </Step>

  <Step title="Build the scheduling-time check into the booking workflow">
    Make it a required step, not an optional one.
  </Step>

  <Step title="Run a batch each morning for the next day's schedule">
    Work the exceptions; have the front desk call those patients today.
  </Step>

  <Step title="Re-check at check-in" />

  <Step title="Save the response to the encounter" />

  <Step title="Estimate patient responsibility from the 271">
    And collect it. Under-collect on uncertainty.
  </Step>

  <Step title="Escalate the ambiguous cases to a phone call">
    And document the call.
  </Step>
</Steps>

## Verify it worked

* [ ] Real-time 270/271 enabled for the payer mix
* [ ] Check at scheduling is a required workflow step
* [ ] Daily batch running for the next day
* [ ] Re-check at check-in
* [ ] 271 responses saved to the encounter
* [ ] Point-of-care estimates derived from the 271, not the card
* [ ] Phone verifications documented with name and reference number
* [ ] Eligibility denials tracked as a root-cause category

## Common failure modes

| Failure                                                       | Consequence                              |
| ------------------------------------------------------------- | ---------------------------------------- |
| Checking once, at scheduling only                             | Denials for coverage that lapsed         |
| Reading the card instead of the 271                           | Overcollection, credit balances, refunds |
| Not saving the response                                       | No appeal evidence                       |
| Assuming the 271 reports authorization requirements           | CO-197 denials                           |
| Missing carve-outs                                            | Billing the wrong entity                 |
| Not checking visit counts or annual maximums where applicable | Denials that look like coverage problems |
| No exception workflow                                         | The batch runs and nobody acts on it     |


## Related topics

- [Get prior authorizations](/guides/billing/get-prior-authorizations.md)
- [Submit clean claims](/guides/billing/submit-clean-claims.md)
- [File appeals](/guides/billing/file-appeals.md)
- [The life of a claim](/concepts/payments/claim-lifecycle.md)
- [Claim denials, explained](/concepts/payments/claim-denials.md)
- [Deductibles, copays, coinsurance, and patient balances](/concepts/payments/patient-responsibility.md)
- [X12 healthcare transaction sets](/reference/edi/x12-transaction-sets.md)