Verifying Benefits Through Availity Without Getting Burned
As more insurance companies eliminate their individual provider portals and move eligibility and benefit verification to platforms such as Availity, practices need to make sure staff understand an important distinction:
Availity is the conduit for the information — the payer is providing the benefit information.
Checking eligibility alone is no longer enough. Your staff needs to know what information to look for, when to verify it, and what to do when the information is incomplete.
A Better Verification Process
Whenever possible, verify benefits 1–3 business days before the patient’s appointment and look beyond “Active Coverage.”
Your staff should confirm:
- Deductible — total AND remaining
- Out-of-pocket maximum — total AND remaining
- Specialist copay
- Coinsurance
- Effective/termination dates
- In-network status
- Service-specific benefits
- Authorization/referral requirements
- Benefit limitations or exclusions
*A verification check-list and staff scripting example is attached below. They have also been added to the resource library*
Don’t assume general medical benefits apply to every podiatry service.
Orthotics, DME, routine foot care, injections, imaging, surgery and other services may have different benefits, exclusions or medical-necessity requirements.
When Availity Doesn’t Give You Enough Information
Don’t guess.
If the electronic response is unclear, incomplete or doesn’t address the service you are providing, contact the payer directly.
Document:
Date + Representative + Reference/Call Number + Information Provided
And remember:
Verification of benefits is NOT a guarantee of payment.
Other claims may be processing, benefit accumulators can change, and final patient responsibility is determined when the claim is adjudicated.
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