Insurance Eligibility & Verification for US Practices

The work behind a clean eligibility check

Insurance eligibility and verification is the check that happens between scheduling a patient and delivering care: confirming the policy is active, mapping what it actually covers, and securing authorization for any procedure code that requires it before the visit takes place.

Most eligibility denials trace back to a check that never happened, or one that happened too early and went stale before the visit. Claimstone assigns a named verification specialist to your schedule, checks coverage directly inside the payer's system, and re-confirms anything that needs authorization before the patient is in the chair.

Runs inside your EHR

We check eligibility and submit authorizations from your existing EHR or practice management system under named logins. Nothing new to install, nothing to migrate.

Named specialist per account

Every scheduled visit has one specialist responsible for its verification and any authorization it needs, not a shared queue that anyone might pick up.

Documented payer rules

Which procedures need authorization, which payers move fastest, and how each plan defines medical necessity are written down, not remembered by one person.

Checked twice, not once

Coverage is confirmed when the visit is booked and rechecked the day before, so a lapsed policy or a changed plan does not surface at the front desk.

Not just a checklist

A checklist tells staff what to ask. Claimstone actually calls the payer, reads the response, and tells your front desk what it means for this patient.

Coverage & Plan Verification

Member ID, group number, plan type, and effective status are confirmed directly with the payer, not assumed from a card that was scanned months ago.

Benefit & Cost-Share Breakdown

Deductible remaining, co-pay, co-insurance, and out-of-pocket maximum are pulled for the specific service being billed, not the plan's generic summary.

Prior Authorization Determination

Every CPT and HCPCS code on the visit is checked against that specific plan's authorization list, since the same procedure can require it under one payer and not another.

Prior Authorization Submission & Tracking

Requests go out with the clinical documentation each payer asks for, then get tracked to a decision instead of being filed and forgotten in a portal.

Real-Time Pre-Visit Re-Verification

Coverage confirmed at booking gets checked again closer to the appointment, since plans change, employers switch carriers, and coverage lapses without warning.

Coordination of Benefits

When a patient carries more than one policy, we confirm which payer is primary before the claim goes out, so it is not rejected and refiled after the fact.

Front-Desk Findings & Patient Estimates

Coverage details are translated out of payer language and into a short summary your front desk can hand the patient before they sit down.

Documentation & Audit Trail

Every check, call, and authorization number is logged against the visit, with a timestamp and reference number that holds up if a claim is later appealed.

No handoffs between scheduling and confirmed coverage

Appointment Scheduled

Patient and procedure details captured at booking, ahead of any verification work.

Coverage Check

Policy status, plan type, and effective coverage confirmed directly with the payer.

Benefit Breakdown

Deductible, co-pay, co-insurance, and out-of-pocket maximum calculated for the specific service.

Authorization Determination

Every procedure code checked against that plan's own authorization requirements.

Authorization Submission

Requests filed with supporting documentation and tracked until the payer responds.

Pre-Visit Re-Check

Coverage reconfirmed shortly before the appointment to catch any late change.

Front-Desk Handoff

Findings and patient responsibility summarized in plain language ahead of check-in.

Documented Close-Out

Every check, call, and authorization number logged against the visit record.

Review your payer mix

We look at your specialty, common procedures, payer mix, and current verification process before proposing anything. If eligibility is not actually your problem, we say so.

Build the verification workflow

Which codes typically need authorization, which payers move fastest, and your escalation path get documented and set up inside your existing system.

Run eligibility on every visit

Coverage and benefits are checked at booking and again before the appointment, with findings sent to your front desk both times.

Manage prior authorization

Requests are submitted with the right documentation, tracked to a decision, and escalated if a payer sits on one too long.

Report and tighten the process

You get recurring reporting and a standing review with your specialist, where recurring denial patterns turn into changes upstream.

Fewer denials tied to coverage

Claims stop getting rejected for reasons that were checkable before the visit ever happened.

Authorizations do not fall through

Every request is tracked to a decision instead of sitting unopened in a payer portal.

Front desk stops guessing

Staff hand patients an accurate summary instead of finding out about a coverage gap at the counter.

Fewer surprise patient balances

Patients hear their cost-share before the visit, not on a statement weeks later.

Room to add volume

Adding a provider or a service line does not mean hiring and training another verification specialist first.

Solo & small practices

Full verification coverage without adding staff, and without checks slipping when the front desk gets busy.

Group practices

Consistent verification across every provider, with reporting broken out by location if you need it.

Specialty practices

Authorization rules built around what your specialty actually bills, not a generic checklist.

Clinics & healthcare organizations

Multi-location volume, split payer contracts, and authorization tracking broken out by site.

Verifications completed

Visits checked for coverage, by period and by provider.

Authorizations obtained

Requests submitted, approved, denied, or still pending.

Eligibility denial rate

Claims denied for coverage reasons a check should have caught.

Authorization denial rate

Requests denied by the payer, broken out by reason.

Re-verification rate

Visits rechecked closer to the appointment.

Pending authorizations

Requests still open, sorted by how close the visit is.

Patient cost-share accuracy

Estimates given before the visit, compared against the final bill.

Payer response time

Which payers answer quickly and which ones routinely stall.

Business associate agreement

A signed BAA is in place before any specialist touches your system or a payer portal.

Role-based access

Named logins only, scoped to verification work, and removed the day someone rolls off your account.

No PHI outside approved systems

Coverage and benefit details stay inside your EHR or PM. Nothing moves to a personal device or an unsecured inbox.

Every check on the record

Timestamps, reference numbers, and payer responses are logged against the visit, the same record we lean on for appeals.

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