An eligibility denial occurs when the payer determines that the patient was not covered, not active, or not eligible for the billed service on the date of service.
What is an eligibility denial?
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Detailed Answer
Eligibility denials can arise from true lack of coverage or from incorrect claim information.
Common causes include:
- Coverage terminated before the date of service
- Wrong member ID
- Incorrect patient name or date of birth
- Wrong payer billed
- Coordination-of-benefits issue
- Retroactive coverage changes
The resolution depends on verifying the patient's coverage for the actual date of service.
Key Points to Mention
- Eligibility must be checked for the date of service.
- Demographic errors can mimic eligibility problems.
- COB can cause apparent eligibility denials.
- Retroactive updates may change coverage status.
Example Scenario
A payer denies for inactive coverage, but the practice finds a new member ID issued after a plan renewal. The claim can be corrected and submitted under the valid coverage.
Common Mistakes
- Checking current eligibility instead of date-of-service eligibility.
- Billing the patient before confirming coverage.
- Ignoring COB.
Interview Tip
Always verify coverage for the actual date of service.