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Importance of Eligibility & Benefits Verification

Eligibility and Benefits Verification

Verifying insurance eligibility and benefits is one of the first and most important steps in the dental RCM process. It is the process of confirming a patient’s active coverage and eligibility with an insurance company. A majority of Americans are insured. As a result, it becomes critical to verify their insurance eligibility before providing any treatment or dental care. Proper eligibility and benefits verification provides the practice with a clear view of a patient’s insurance coverage, benefits and payment obligations so that they can submit clean claims without any mistakes. With today’s changing and increasingly complex insurance payment processes, it becomes necessary to pay careful attention to the verification of coverage, benefits, co-payments, and unpaid deductibles. Most claim denials occur because of errors in eligibility checks, while every successful insurance payment is largely dependent on successful eligibility and benefits verification.

Processes Involved in Eligibility and Benefits Verification

1. Patient Scheduling and Enrollment:

The first step in eligibility and benefits verification includes scheduling patient appointments. This can be done through phone calls, text messages, or online booking methods. During the appointments, the patient’s information as well as patient health details are to be collected. Essential information such as patient name, phone number, address, medical history, diagnosis and more is to be collected carefully without any mistakes.  

2. Patient Insurance Verification:

It is one of the most important processes, where the patient details such as insurance coverage, benefits and more are verified and cross checked. It is usually done before the patient’s appointment. While carrying out the eligibility and benefits verification on a patient ensure that the information obtained is correct and up-to-date. Any error in this information can lead to denial of claims. With the frequently changing insurance processes, it is important to remain up-to-date so that you don’t make any mistakes. Check through the information and claims thoroughly as many times as possible, because denied claims can be a huge hassle.

3. Collecting additional information from the patients and the insurance company: 

Collecting accurate information is key to efficient eligibility and benefits verification. If any doubt arises about the patient information or insurance coverage details, make sure to contact the patient or the insurance provider if needed. It can be through a simple text or call. It could help in clearing doubts and staying up to date, thereby producing clean claims without any errors. In case of doubts regarding the insurance coverage, you can always contact the insurance provider for more clarity. But make sure you always collect precise information.

4. Updating the RCM System: 

The revenue cycle management system needs to be updated with the collected patient information and insurance coverage details. Make sure to update it correctly without any errors. This is the last stage in eligibility and benefits verification and therefore must be given careful attention.

Benefits of Eligibility and Benefits Verification

1. Submission of Clean Claims

Eligibility and benefits verification help you submit error free clean claims. It helps eliminate all errors in insurance claims before submitting them. The various patient information and insurance coverage details are cross checked before updating. This helps in avoiding any errors that may occur in patient information and insurance details. This makes the whole payment process easier and quicker.

2. Lower Claim Denials: 

Since all the errors are rectified during the eligibility and benefits verification stage itself, there is only a very low chance of claim denials. Submission of clean claims reduces the rate of claim denial and increases the claim acceptance rate. The complicated task of reworking and resubmitting denied claims can thus be avoided, making the payment process a lot easier.

3. Increase in Cash Flow: 

With an increased claim acceptance rate and a low denial rate, the revenue of the practice increases significantly.  Consistent and accurate eligibility verification is important for the consistency in the cash flow in a dental practice. Any error in this can impact the overall revenue of the practice. In cases where the policies do not cover the dental services or have expired, eligibility and benefits verification protects the practice from any impact on revenue and improve the overall cash flow.

4. Increased Patient Satisfaction:

Patients are the main priority in any practice, and eligibility and benefits verification help in providing your patients with quality services and giving them maximum satisfaction. Efficient eligibility and benefits verification enables you to be transparent with your patient through open communication, thereby earning their trust. It will also inform the patients about their responsibilities prior to their appointment so that they can come to the appointment with proper payment preparation. This gives them a sense of security and satisfaction and would make them want to continue service with you.


Failure to carry out proper eligibility and benefits verification can have a huge negative impact on the overall functioning of your practice. It affects almost all aspects, including cash flow, patient care and experience, insurance payment and dental billing and more. Any mistake in the eligibility and benefits verification process can lead to an increase in claim denials, a complex process of rework and resubmission, delays in patient care, which impacts the patient experience and satisfaction, and increased payment debts. In fact, it is very important for practices as well as patients to understand the eligibility and benefits verification process and its importance in facilitating fast and easy insurance payment. But with the changing insurance rules and policies, it becomes really difficult for the practice as well as the patients to stay on top of these requirements. Not just that, managing the insurance payment processes, including eligibility and benefits verification, along with patient care and other needs, can prove to be a really laborious job, disturbing the complete functioning of the dental practice. Therefore, most people nowadays opt for an RCM service provider. They help you manage all aspects of your revenue cycles so that you can provide your complete attention to patient care and experience.

A dental RCM service provider helps you stay up to date with the changing dental insurance rules and regulations in insurance payment so that you can give your undivided full attention to patient care, thereby increasing patient satisfaction. They interact with the practice as well as the insurance company, handle the paperwork, and verify patient information, thereby improving the revenue cycle and maximizing payment. They can do the work with maximum efficiency and save the practice and its staff extra time, effort and energy. An RCM service provider could be the ideal solution for managing the complex tasks of eligibility and benefits verification and insurance payment. 

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