Eligibility Check

Eligibility Check – Plan Policy

Physicians (MD/DO)
Policy/Plan Effective and Cancellation Dates – Following are the set of Validations that are performed as part of this process
Claim DOS should be after the Policy/Plan’s effective date
Type of Plan Type of plan checks ensure that the plan covers the service that has been provided to the member.

Policy Plan Validation

This process involves checking whether the policy submitted on the claim exists / it is a valid policy. –These claims need to be validated against regular checks that have to be carried out for every claim. Eligibility check process identifies member claims which cannot be processed further due to member information related issues. Eligibility check process can be divided into below sections.1. Policy Plan Validation 2. Determination of Eligibility Start and End Date

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