Insurance Eligibility Verification Automation
Catch coverage problems before the visit — not after the claim is denied.
Short answer: Eligibility verification automation uses AI to run real-time insurance benefit checks (the 270/271 EDI transaction) before each visit — confirming active coverage, copays, deductibles, prior-auth requirements, and plan rules automatically. RCM Employee's eligibility Digital FTE does this API-first via Medicare HETS, UHC/Aetna FHIR, and Stedi/Availity, so front-end denials drop and first-pass claim acceptance rises.
Why eligibility is where denials begin
A large share of claim denials trace back to front-end eligibility errors: inactive coverage, wrong payer or plan, term dates, missing referrals, or unmet prior-auth. Verifying eligibility automatically — for every patient, every visit — removes that root cause.
What automated eligibility checks return
- Active/inactive coverage and effective/term dates
- Copay, coinsurance, deductible, and out-of-pocket status
- Plan type, network status, and COB (coordination of benefits)
- Prior-authorization and referral requirements
- Batch eligibility for tomorrow's full schedule, run overnight
How it works (API-first)
The eligibility agent sends a 270 request and parses the 271 response in real time — no portal logins, no screen scraping. Medicare runs free via CMS HETS; UHC and Aetna via direct FHIR; everything else via the Stedi/Availity clearinghouses. Every check is encrypted and audited.
Built for every U.S. provider type
- Solo & small practices — verify the whole day's schedule without a dedicated front-desk verifier.
- Group & specialty clinics — catch plan-specific rules and prior-auth needs early.
- Nurse practitioners & behavioral health — confirm benefits and visit limits up front.
- Hospital outpatient & urgent care — high-volume batch eligibility.
Frequently asked questions
- What is eligibility verification automation?
- AI runs real-time 270/271 benefit checks before visits, replacing manual payer calls and portal work.
- Does it work in real time and in batch?
- Both — instant checks at scheduling/check-in, and overnight batch for the next day's schedule.
- Is it HIPAA compliant?
- Yes — API-only, encrypted, per-practice isolation, BAA chain, and a 7-year audit log.