APPOINTMENT AND SCHEDULING

ELIGIBILITY AND BENEFIT VERIFICATION

Objective

By the end of the session participants would be able to understand -

Appointment & Scheduling

Appointment Form

Eligibility & Benefit Verification (EBV) and it's Terminologies

Appointment & Scheduling
Appointment Scheduling Flow Process

Patient makes an appointment with the provider

by Calling, Online or visit to provider's office.

The provider's office collects all relevant

information from the patient

The information collected is saved in system

so that the same can be verified during
Eligibility and Benefit Verification stage

A reminder is set so that after the

provider's discussion with payer, the
call can be returned to the patient
and finally appointment is
scheduled/fixed
Details Collected During Appointment and
Scheduling
An appointment form contains the
following information about the
subscriber and patient:

Name, Address & Contact#

Unique identification number like Social

Security Number (SSN ) or Insurance
policy number.

Date of Birth ( DOB )

Date and Time of Visit

Insurance name & Policy Number

The provider's office person will make a

note of all the information in his system
so that the same can be validated with
Insurance
Eligibility and Benefit Verification (EBV)

During Appointment & Scheduling,

provider obtains patients Insurance
information and schedules an
appointment.

In Eligibility and Benefit

Verification (EBV) the information
obtained is shared with the
insurance.
Eligibility Check and Benefit Verification
Process
The provider's office does an overview of all the
information collected from Appointment and
Scheduling stage

Cross checking the details by calling Insurances and

verifying Eligibility and plan benefits in regards to the
service to be rendered by our provider.

Documenting the correct eligibility & benefits

information obtained from the payer and sharing
the same info with patient

Financial Advise discussion with the

patient and finally an appointment is
scheduled
Medical Terminologies Related to EBV

COOLING PERIOD :-The time gap between the enrollment

date and the effective date is known as Cooling Period.

PRE EXISTING Condition :-The illness / sickness / injury

or disease which the patient is suffering from before
purchasing the policy.

WAITING PERIOD :-
The time gap between the effective date and the date
beginning which insurance will be responsible for a
payment on pre-existing diseases, is known as Waiting
Period.
Waiting period clause is only for a pre existing condition
Medical Terminologies Related to EBV

Coverage Period
The period between the effective date and
termination date

Covered Services
The services that will be covered by the
insurance according to the patient's plan or
provider's contract

Maximum Benefits
These are the maximum benefits that the
insurance will cover for the subsciber's policy
Medical Terminologies Related to EBV

Prior authorization / Pre-certification / Prior notification :-

The Insurance Companies would require the providers to take an approval or
permission before rendering certain services which are generally of high cost.
The Insurance Company gives a number as an acknowledgment for the approval and
that number is called as Prior Authorization Number.
It is needs to mentioned in the claim form ( Block#23) while submitting the claim to
insurance / payer. Authorization is not applicable for emergency services

Retro Authorization :
In case the provider fails to get a Prior Authorization due to some unavoidable
circumstance, he / she can inform the same to the Insurance Company after
rendering the service within 72 hours of duration.
If the reason for not taking Prior Authorization is valid, the Insurance Company may
still approve the service and this process is called as Retro Authorization.
Lets Summarize

Appointment and SCHEDULING is the process whereby patient takes an appointment and proceeds
with registration formalities with the provider.

APPOINTMENT FORM is to be filled by the patient to take an appointment from the provider.

CO ORDINATION OF BENEFITs is a document which classifies Primary, Secondary and Tertiary

Insurance.

INSURANCE CARDs are the documents which shares policy details & beneficiary details.

Prior and Retro Authorization