Medical Office Workflow Step 2: Proper Insurance Verification

For successful claims processing and payment, it all starts with the proper verification of insurance coverage and benefits.

proper claims reimbursement

Follow the guide below to ensure you are gathering all the necessary information to create a complete and accurate patient benefit profile.

medical billing hintBasic information needed before contacting the insurance company:

1.       First and last name of patient and the subscriber (if other than the patient)

2.       Patient’s date of birth

3.       Policy number as shown on the insurance card

medical billing hint(The insurance card is one piece of essential information your patient should bring on their first visit.  Please see this New Patient Checklist other important documents, etc.)

4.       Diagnosis or chief complaint

5.       CPT codes for anticipated procedures

verify medical benefitsAsk these questions to build your patient benefit profile:

1.       What are the effective dates of the current policy?

2.       Are they any pre-existing conditions limitations?

3.       What are the benefits for the anticipated service?

a.       Does a deductible apply (see b) or only a copayment (see d)?

b.      If there is a deductible, how much is the deductible and how much is met?

c.       After the deductible, what is the co-insurance amount?

d.      How much is the copayment?

e.      What is the annual out of pocket maximum and how much is met?

f.        Do the deductible and copayments apply toward meeting the out of pocket maximum?

4.       Does this policy require any type of authorization of the anticipated service(s)?    If yes, make sure to obtain the proper contact information for that internal department or outside agency.

verify medical benefitsIf you are unaware of the entities process for obtaining authorizations, immediately contact them by phone or review available information on their website.  This is a huge time saver to have this information on hand before you may actually need it. 


5.       Is there an annual, lifetime or per illness/diagnosis maximum benefit?  If so, how much has been met?

medical billing termsIf some of the above terms seem confusing, refer to the table below for helpful explanations.



Pre-existing Condition

Most often occurs with a lapse of insurance coverage.  The new insurer can refuse to cover a condition that was diagnosed before the effective date of the policy.


Amount the subscriber is responsible to pay before insurance will pay their portion.


A flat rate assigned to specific procedures that the subscriber is required to pay.  Most commonly to office visits and outpatient diagnostic procedures. 


The percentage of the charge that is the subscriber’s responsibility.  Refers to benefits like”80/20”, the insurance pays 80%, the patient pays 20%.

Out of pocket Maximum

This is the total patient’s out of pocket financial responsibility designated by the payer.  Once the subscriber has met this amount, services then become covered at 100% by the payer.

Benefit Maximum

This is the monetary payment limit set on the subscriber’s policy.  Once this maximum is reached the payer has no more financial liability and the subscriber must pay for the rendered services.


Iridium SuitePractice Management software from Medical Business Systems has an integrated insurance Real Time Eligibility function that can do most of this work for you.  See how Iridium Suite can help you “work smarter not harder”.