Executive summary. An eligibility check clarifies current coverage. It does not promise that a particular service will be paid.
Definition
Eligibility verification is checking a patient’s coverage information for a particular time and service context.
Where this work lives in Attergo
The Attergo Billing Dashboard, Encounters, Claims Queue, Eligibility Workspace, Submissions, Denials, and Payment Posting follow the work from service through to payment. Start at the encounter or claim in question, record the next action there, and let the queue carry what is still unresolved.
Coverage depends on the plan, the benefit, the network, the service, the date, and the patient’s own responsibility. An “active” result is useful, and it can leave most of the questions about a planned clinical service still open.
Review and follow up
Explain coverage to patients carefully. Avoid promising payment before the payer decision is known, and document what you were told in line with your organization’s policy.
Final decisions stay with the role your organization holds accountable for them. Record the decision on the item, with the evidence behind it, so the next person to open it does not start over.
Frequently asked questions
Who should use this Attergo workspace?
The role that owns the next action leads it: a billing specialist, an authorization coordinator, an inventory lead, a pharmacist, a compliance lead, or a finance reviewer. Access follows the role your organization assigns.
Referenced standards and further reading
- CMS: Eligibility and benefits transactions ↗Centers for Medicare & Medicaid Services
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