© 2017 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Name: __________________________________________ Date: _____________ Score: _____________
Competency Checklist
Procedure 27–1 Verify Insurance Coverage and Eligibility for Services
ABHES Curriculum
MA.A.1.8.c(2) Differentiate managed care; i.e., HMO, PPO, EPO, IPA including referrals and pre-certification
CAAHEP Core Curriculum
VI.P.7 Input patient data utilizing a practice management system
VII.C.5 Identify types of information contained in the patient’s billing record
VII.C.6 Explain patient financial obligations for services rendered
VII.P.4 Inform a patient of financial obligations for services rendered
VII.A.1 Demonstrate professionalism when discussing patient’s billing record
VII.A 2 Display sensitivity when requesting payment for services rendered
VIII.C.1 Identify: (a) types of third party plans, (b) information required to file a third party claim, and (c) the
steps for filing a third party claim
VIII.C.2 Outline managed care requirements for patient referral
VIII.C.3 Describe processes for: (a) verification of eligibility for services, (b) precertification, and (c)
preauthorization
VIII.P.1 Interpret information on an insurance card
VIII.P.2 Verify eligibility for services including documentation
VIII.A.1 Interact professionally with third party representatives
VIII.A.3 Show sensitivity when communicating with patients regarding third party requirements
Task: Interpret information on a patient’s insurance card and verify the patient’s insurance coverage
and accurate billing information prior to rendering service to prevent claim rejection due to
patient ineligibility for coverage.
Supplies & Conditions: Computer, patient insurance identification card, insurance website address, individual password
for access on website, and telephone.
Standards: A maximum of three attempts may be used to complete the task. The time limit for each attempt
is 15 minutes, with a minimum score of 70 percent. Scoring: Determine student’s score by
dividing points awarded by total points possible and multiplying results by 100.
EVALUATION
Evaluator Signature: Date:
Evaluator Comments:
451
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© 2017 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Name: __________________________________________ Date: _____________ Score: _____________
Procedure 27–1 Steps
Start Time: End Time: Total Time:
Steps
Possible
Points
First
Attempt
Second
Attempt
Third
Attempt
1. Interpret the information on the patient’s insurance card.
Determine if the insurance is managed care (HMO,
PPO, EPO, IPA). Access website for patient’s insurance
carrier or the EHR application with electronic eligibility
features. If website is not available, call the insurance
company. Interact professionally with third-party
representatives.
15
2. Locate the section of the website for Provider
Information.
10
3. Enter protected area of website. 10
4. Access area of website for verifying eligibility. 10
5. Complete all required fields on the screen. 15
6. Verify on screen that you have the correct patient
information and that the patient is eligible for services.
15
7. Print results for inclusion in the patient’s record either
on paper or enter or scan the results in a practice
management system of an EHR.
15
8. Notify the patient if the insurer indicates that he or she is
not eligible for services. Demonstrating
professionalism when discussing the patient’s billing
record, ensure that you show sensitivity when
communicating with patients regarding third-party
requirements. Display sensitivity when requesting
payment for services rendered.
15
Points Awarded / Points Possible _____/
105
452