Why eligibility is where denials start
A denial in stage 07 is usually a mistake made in stage 01. When coverage has lapsed, a plan has changed or a referral was never on file, the claim is already lost by the time it is coded — and no amount of scrubbing will save it.
Stale eligibility is the single biggest leak for practices with long gaps between visits, such as family medicine and primary care. Pediatric practices see the same pattern when Medicaid redetermination moves families between plans without notice. The denial that follows — CO-27, coverage terminated — is entirely preventable.
What we check, every visit
Verification runs ahead of the schedule, not at the front desk while the patient waits.
- Active coverage on the date of service
- Co-pay, co-insurance and remaining deductible
- Referral and authorization requirements for the visit type
- Primary versus secondary payer order
- Plan changes since the last visit
How it feeds the rest of the cycle
Eligibility results flow straight into registration and intake QA, where demographics and insurance details are corrected while errors still cost nothing to fix. When a visit needs prior authorization, it is flagged here so the request is filed before the appointment, not after the denial.
Because we run the whole loop, denial reasons we see in stage 07 are fed back upstream. If a payer keeps rejecting for coverage, the verification step changes — monthly, in writing.
How verification is done
Most checks run electronically through the clearinghouse or payer portal as an eligibility inquiry and response. When the response is incomplete — behavioral health carve-outs, Medicaid managed-care assignments, out-of-network benefits — we call the payer and note the reference number. The result is recorded in your practice management system, so the front desk can tell the patient what they owe before the visit rather than after the statement.