How do you resolve an eligibility or coverage denial?

I would verify the patient's coverage for the date of service, compare payer and demographic information, review COB, and determine whether the claim needs correction, rebilling to another payer, or appeal.

The correct workflow depends on what the verification shows.

I would confirm:

• Member ID
• Patient name and date of birth
• Coverage effective and termination dates
• Plan type
• Primary and secondary payer order
• Whether coverage was retroactively updated

If the patient truly had no coverage, the account may move to patient responsibility subject to practice policy and applicable rules. If the payer's eligibility record is wrong or outdated, the account may require appeal or payer correction.

• Verify date-of-service coverage.
• Review demographic data.
• Check COB.
• Use the correct payer when coverage changed.
• Do not transfer to patient prematurely.

A claim denies for no coverage, but the payer portal shows the patient was active after a retroactive reinstatement. The AR representative submits reconsideration with proof of eligibility.

• Checking only today's eligibility.
• Ignoring retroactive reinstatement.
• Billing the patient before completing insurance research.

Show that eligibility denials can require correction, rebilling, or appeal depending on the facts.