Eligibility verification is a crucial step in the claims process for both Medicare and Medicaid. By confirming a patient's eligibility before submitting claims, healthcare providers can avoid errors, reduce claim denials, and ensure timely reimbursement. Here’s a comprehensive guide on how to perform eligibility verification for both programs.

Step 1: Obtain Patient Information

Start by gathering accurate patient information, including their full name, date of birth, and insurance details. For Medicare, you'll need the Medicare number, while for Medicaid, you’ll need the Medicaid ID number along with relevant demographic information.

Step 2: Use Online Portals for Verification

For Medicare, you can use the Medicare Administrative Contractor (MAC) Portal or access the Eligibility Transaction System (ETS) to verify patient eligibility. For Medicaid, each state has its own eligibility system, which you can access through state-specific portals or eligibility verification tools.

Step 3: Review Coverage Details

Once you input the patient’s information, the system will provide details about their eligibility, including coverage for Part A, Part B, and, if applicable, Part C or Part D (Medicare), or the services covered under the state’s Medicaid plan. You should also check for secondary insurance information if applicable.

Step 4: Confirm Service Coverage

Ensure that the services you plan to provide are covered under the patient’s Medicare or Medicaid plan. Some services may require prior authorization or have service-specific limitations.

Step 5: Document Verification Details

Record the verification results, including the date of verification, coverage status, and any relevant details like co-pays, deductibles, or limitations. This will help you avoid claim denials and ensure accurate billing in the future.

Why Eligibility Verification Matters

Verifying a patient’s eligibility for Medicare and Medicaid helps reduce administrative costs and ensures that both patients and healthcare providers have a clear understanding of what is covered under the insurance plan. It also reduces the risk of payment delays or claim denials due to eligibility issues.

How Mastermind Healthcare Can Assist

At Mastermind Healthcare, we offer comprehensive revenue cycle management services, including eligibility verification. Our team ensures that your claims are processed smoothly by confirming patient eligibility, checking coverage, and ensuring proper documentation before submission. This helps minimize denials and optimize reimbursement rates.