Eligibility Check
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
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 – Plan Policy
- 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
- Claim DOS should be before the Policy/Plan’s end/Cancellation date – Claims that fail this check result in pended status or are reviewed by manual adjusters for further processing. – Reasons for cancellation of policy may vary from government approval to viability of the policy.
- Type of Plan Type of plan checks ensure that the plan covers the service that has been provided to the member.