Healthcare agent

Eligibility verification

Check coverage and eligibility against payer data and flag issues before the visit.

What it does

When the next day's schedule is released, the agent runs every booked patient through the eligibility clearinghouse and returns the appointments where coverage is inactive, the plan on file does not match registration, or the benefit does not cover the booked service. Staff work that list before the patient arrives.

Without it: Eligibility surprises at the desk delay care and create avoidable billing problems.

Checks secondary and tertiary coverage on file, not only the primary plan
Retries a clearinghouse timeout, then lists the patient as unverified rather than clear
Puts the payer's own response code beside each flag for the staff call
Orders the list by appointment time so the desk works it in arrival order

Illustrative example

Tomorrow's orthopaedic clinic schedule is released overnight. The agent returns the appointments that need a call: two plans terminated at the end of last month, one where registration holds the spouse's policy and the clearinghouse holds the patient's own, and one injection visit the benefit excludes, each with the payer response code beside it and sorted by slot time. The front desk works that list before the doors open, and sends the excluded injection visit to financial counselling.

Reads

Scheduling system

Tomorrow's booked appointments

Practice management

Plans on file

Eligibility clearinghouse

Payer coverage responses

Patient registration

Policy as registered

Runs

Eligibility verification

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