Discover the Insurance Verification Standards
Insurance verification standards refer to the rules, protocols, and best practices used by healthcare providers, insurers, and clearinghouses to verify a patient’s insurance coverage before services are rendered. The goal is to confirm eligibility, benefits, and policy details accurately and consistently—reducing claim denials, improving revenue cycle efficiency, and ensuring regulatory compliance. Our system will verify claims from hospitals based on insurance verification standards.
Key Elements of Insurance Verification Standards
1. Eligibility Verification
- Confirm the patient’s active coverage status.
- Check coverage start/end dates, insurance type, and plan details.
2. Benefits Validation
- Confirm services are covered under the patient’s policy.
- Validate co-pay, coinsurance, deductibles, and pre-authorization requirements.
3. Standard Data Elements
Typically required fields include:
- Insurance payer ID
- Patient name, DOB, insurance ID
- Provider NPI, Tax ID
- Service type (e.g., office visit, surgery)
- Date of service
4. Standardized Format and Protocol
Diagnostic, Procedure and Medicine:
- ICD-10 (Diagnose)
- ICD-10 PCS (Procedure Coding System)
- UNII (Unique Ingredient Identifier)
These are ANSI X12 EDI formats used for electronic insurance verification in the U.S.
5. Real-Time Eligibility (RTE) Checks
- Conducted via API or clearinghouse integration with payer systems.
- Used at check-in or before procedures to reduce rework and denials.
6. Verification Frequency
- Usually done at every visit or procedure, even for returning patients.
- Especially critical for services requiring prior authorization or for plans that change frequently.
7. Compliance and Privacy Standards
- Must comply with regulations for handling patient and insurance data.
- Secure transmission and storage of verification records.