Claims process

What is Eligibility verification?

Confirming a patient’s active coverage and benefit details with the payer before the service is rendered.

Also known as
insurance verification · benefits verification · 270/271

Definition

Eligibility verification is an electronic exchange — a 270 inquiry and a 271 response — that confirms whether coverage is active on a given date and what the benefits are: deductible remaining, copay, coinsurance, and often whether authorization is required.

The distinction that matters operationally is between checking eligibility and checking benefits. Active/inactive status prevents termination denials; the benefit detail is what lets you quote the patient an accurate out-of-pocket figure and collect it at the time of service, which is when it is cheapest to collect.

Why it matters

Eligibility and registration errors are among the largest denial categories in healthcare, and nearly all of them are caught by a verification run on the day of service.

Denial codes to know

PR-27 · Expenses incurred after coverage terminatedCO-31 · Patient cannot be identified as our insuredCO-140 · Patient ID number and name do not matchPR-177 · Patient has not met eligibility requirements

Related terms

Prior authorizationCoordination of benefitsDenial rate

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