Verifying eligibility and effective dates - Capitation and/or delegation supplement - 2022 Administrative Guide

For information on ways to verify eligibility, refer to Verifying eligibility, benefits and your network participation status in Chapter 2: Provider responsibilities and standards. This helps ensure you:

  • Submit the claim to the correct payer.
  • Collect copayments.
  • Determine if a referral, prior authorization or advance notification is required.
  • Reduce denials for non-coverage.

We can provide you with daily and/or monthly member eligibility information using an electronic file. You must coordinate initiation of electronic eligibility files with your software vendor and us. Advantages of receiving electronic eligibility are:

  • Lower cost and effort required to maintain eligibility manually.
  • Faster updates loaded into your system.

Refer to ASC X12 Technical Report Type 3/Companion Guides or ask your health care provider advocate for more information.