At the top, write the member name, member ID, group number, insurer, plan name, employer or plan administrator if applicable, and the plan year. Add columns titled “insurer answer,” “facility answer,” “written source,” “status,” “date checked,” and “follow-up.” Use only three status labels: confirmed, needs review, and not established. “Confirmed” should mean that you have current, specific support for the statement, preferably in writing. It should not mean guaranteed payment.
Eligibility answers whether the policy is active on a stated date. Ask: “Is this policy active today?” “When did coverage begin?” “When does the plan year reset?” and “Are there exclusions or coordination-of-benefits issues that could affect a claim?” Active insurance does not establish that a particular facility, level of care, or service is covered. Write eligibility on its own row so it cannot be mistaken for authorization or provider participation. If coverage may change before admission, note that the answer must be rechecked.
- Eligibility: active status, effective date, plan-year dates, and any issue requiring follow-up
- Authorization: whether prior authorization or another review is required, who submits it, and when
- Provider status: the exact legal entity, facility location, and whether each relevant billing provider is treated as in network or out of network-f-f-f-f-f-f-f-f-f-f-f-f-f-f-f-f-f-