Create A Member Eligibility Form for New Patients

Apply a member eligibility form to properly verify out-of-network health insurance benefits.

Step 1: Document the Policy Number

  • Obtain the front & back of the ID card

Step 2: Call the Health Plan Provider

  • Record the Date, Time, & Number of the call
  • Name of the Representative & Reference Number for the call

Step 3: Obtain Employer Name and Address

  • Needed to Order Plan Documents

Step 4: Ask If Pre-Authorization is Required?

  • If not, then state clearly on your eligibility form/checklist
  • If yes, then get a written authorization along with the Authorization number which must be clearly recorded on the verification form/checklist

Step 5: Calculate the Patient Responsibility

  • Obtain OON deductible amount and verify the amounts satisfied at time of service
  • Based upon the information obtained about the OON deductible, you should be able to calculate the amount of the deductible that will be applied to your OON claim
  • Obtain OON out of pocket maximum and verify the amounts satisfied at time of service. Once this is satisfied, the plan will allow at 100% of the out of network benefits (but not 100% of charges)
  • Based upon the information obtained about the OON out of pocket maximum, you should be able to calculate the amount of the out-of-pocket maximum that will be applied to your OON claim
  • Obtain coinsurance percentage applicable to OON benefits

Step 6: Check How Plan Allows OON Benefits

  • Does the plan allow OON benefits based upon (a) UCR or R&C or (b) internal fee schedule or (c) A percentage of the Medicare fee schedule

Next-Steps: Provide the Necessary Disclosures

Once eligibility is verified, make sure that you provide the patient with all the necessary disclosures so you don't fall into issues down the line.

For more details on how to do this download our guide here.