Electronic Benefits Verification: Getting Started
Health insurance is a type of insurance coverage that pays—in part or in whole—for the medical and surgical expenses incurred by the people the policy covers. In this guide, you’ll learn how to find out what expenses an insurance company will cover for a patient, what additional documentation requirements an insurance company may require, and how you can complete these workflows electronically in WebPT.
IN THIS ARTICLE
Insurance Benefit Verification
To find out what expenses a patient’s insurance company will cover, you need to follow a process known as insurance benefit verification. Simply put, insurance benefit verification is the process of contacting an insurance company to identify what expenses they will cover for the patient. The information provided by the payer has an impact on your entire clinic.
The Front Office will use this information to know if a patient’s policy is active, if a referral or prior authorization is required, what the policy expiration date is, and if there is a limit to the number of visits they will cover for the patient.
Providers will use this information to plan their treatment. Sometimes insurance companies will not cover certain procedures, such as dry needling, or may limit the number of times you can bill for a particular service.
The Back Office will use this information to ensure that claims meet the documentation requirements of the insurance company, and that the services provided are covered. This will help to reduce the number of claims denied by the insurance company.
WebPT Electronic Benefit Verification (eBV) aims to give that time back to your clinic, by submitting the insurance benefit verification request directly from within the EMR, drastically reducing the amount of time you spend on the phone with insurance companies.
When you send a request to verify benefits, the payer will verify that the request was sent by a provider or organization that is contracted to provide services with them. To verify the identity of the requestor, the insurance company will use either the Individual NPI of the provider, or the Group NPI of the practice. Before we can verify benefits, we need to make sure these are correctly entered in the WebPT EMR.
From the EMR Dashboard, click the company drop-down menu and select Clinic Settings.
Scroll to the section titled Group NPI for Electronic Benefit Verification.
Enter your Group NPI number.
Click Save Settings.
From the EMR Dashboard, click the company drop-down menu and select User Manager.
Use the User Search field to find a provider whose NPI may be used to verify benefits.
Click Edit to view the profile details.
Verify that the number in the NPI# field is correct.
Click Save User.
Now that we’ve verified that the NPI’s we’ll be using to verify benefits are correct, there is one more piece of setup we need to complete before we can begin verifying patients’ insurance benefits: Mapping Insurances.
The Insurance Mapping part of the Electronic Benefit Verification process is similar to knowing which phone number to call for each insurance company. Medicare, Blue Cross Blue Shield (BCBS), Aetna, and all other payers have their own phone number to call when you want to check the benefits for a patient with their insurance, and they also have their own place to send electronic requests. Mapping Insurances tells us where specifically to send the electronic benefit verification request.
Insurance Mapping Tips
- Use the Export Electronic Payer List to determine the mapping source instead of depending on the payer drop-down to match the Electronic Verified Payer within the insurance payer settings. You can find the Export Electronic Payer List link by clicking on Display Insurance from the Insurance Manager menu.
- There may be payers who are not on the list as not all payers are currently offering electronic verification of benefits.
- HMAA - Hawaii Medical Assurance Association is not supporting benefit transactions at this time
- Tricare East does not currently provide electronic benefits for Professional Services/Physical Therapy
- Auto, personal injury, and workers compensation type payers do not support Electronic Benefit Verification at this time.
- Larger insurance companies often identify their subsidiary insurance companies regionally or by state. These insurance companies may require you to choose the top payer in the hierarchy to obtain benefits. In the following examples, you would choose the bolded insurance payer:
- AARP Medicare Advantage > United Healthcare
- Humana Gold Plus > Humana
- Medicare Plus Blue PPO> BCBS of Michigan
If you are used to finding specific payer IDs when submitting claims, for this transaction type, we recommend locating the top payer or main payer name.
- When the Payer is Medicare, select Medicare Part A and B from the Electronic Verified Payer drop-down.
- For Medicare Replacement insurances ( also known as Medicare Advantage plans), map the insurance to the electronic verified payer of the company providing the plan. (For example, a Medicare Advantage plan provided by Aetna should be mapped to Aetna’s verified payer, not Medicare Part A and B.)
- Mapping Blue Cross Blue Shield (BCBS) out-of-state plans to your local or regional brand may result in rejected benefits.
- Use Blue Exchange for out-of-state Blue-type home plans, to help avoid benefit rejections.
- For any in-state BCBS plans, or BCBS owned plans (such as Highmark), we recommend mapping to the Blue Cross Blue Shield verified payer for your state.
You can potentially avoid these rejections, by adding an additional Insurance Payer profile and mapping it to Blue Exchange.
Electronically Verify Patient Insurance Benefits
Now that our NPI numbers are verified and insurances are mapped, we can electronically verify patient insurance benefits!
Click here for a video walkthrough and article about how to Electronically Verify Patient Benefits in WebPT.
Electronic Benefit Verification Tips
CMS requires a one-time validation and approval of each NPI submitting electronic verification for Medicare insurances mapped to Medicare Part A and B. This results in an immediate benefit verification rejection the first time an NPI is used to verify Medicare benefits. After the first request is submitted, please allow two days to validate and approve the NPI submitted, then initiate another attempt to electronically verify benefits.
When a patient has a Medicare Advantage plan, enter the Subscriber ID provided by the insurance company in the patient chart, not the MBI from their Medicare card.
Returned Benefits Verification .PDF
After a successful verification, a .pdf file will be added to the eDoc section of the patient chart, which contains all of the information that the insurance company responded with. Responses from payers can vary greatly, so the information contained in this .pdf file will differ from patient to patient. Because we can only surface the information provided by the insurance company, there may still be some scenarios where you need to call.
When you verify a patient’s insurance benefits, you’re looking for 6 key pieces of information:
- Is there an annual visit limit for PT, OT, or SLP? Has the patient used any visits towards that limit so far?
- What are the policy dates?
- Does the patient have a copay, coinsurance, or deductible that applies to PT, OR, or SLP?
- Is prior authorization required?
- Is a referral required? If yes, from whom?
- What telehealth coverage, if any, is offered?
Below, we’ll look at how to find each of these pieces of information, and what to do with them in WebPT.
Note: Responses between payers vary widely. Some payers may not include certain pieces of information, and some may display information in different areas of the .pdf. While your Returned Benefits Verification .pdf may not look exactly the same as in these screenshots, this guide will still be able to point you in the right direction.
The visit limit is the number of visits for which the insurance company will share expenses with the patient. This information is typically listed by specialty on the returned benefits .pdf.
Policy dates tell you if the patient’s insurance policy is currently active, and if it has a planned expiration date. This information is found in the section titled Eligibility Result.
Copay, Coinsurance, and Deductibles
The copay and coinsurance information can typically be found in the Eligibility Result section. Remember, the amount and format of information can vary from payer to payer.
Some payers may also provide this information further down on the .pdf, and the information will be listed by specialty.
The deductible is typically displayed on the first page of the .pdf in a section titled HBPC Deductible OOP. Some payers include more information about deductibles than others.
In WebPT, the visit limit (A), policy dates (B), copay, coinsurance (C), and deductible (D) are all entered with the Policy Information on the patient chart. Click here to learn more about adding insurance to a patient chart.
Note: Information added to the Summary of Financial Responsibility field, such as remaining deductible, will appear on the printed Patient Demographics attestation. Click here to learn more.
Prior authorization is a process followed by insurance companies to determine if they deem the patient’s treatment medically necessary. If an insurance company requires prior authorization, it’s some additional paperwork to fill out. Some payers do not indicate if a prior authorization is required—or if an authorization has any limitations—in their returned benefits .pdf, so you may still need to make calls to determine if prior authorization is required.
For example, Cigna works with American Specialty Health (ASH) for their authorizations. When verifying benefits for a patient with Cigna, you would use eBV to get the information from Cigna, then contact ASH for the authorization information.
When prior authorization information is included in the returned benefits .pdf, it will typically be in the Detailed Result section.
In WebPT, information about Prior Authorization and Referral requirements is added when adding or editing a case on the patient’s chart.
When an authorization is required, the information about the authorization is entered at the case level. Click here to learn more about adding an authorization to a patient chart.
In a time where things can change at a moment’s notice, it also helps to know what kind of telehealth coverage an insurance policy may offer. If offered, this information can be found in the Eligibility Inquiry Report section.
In WebPT, information about telehealth coverage can be kept in the Additional Info field when adding or editing a case on a patient’s chart.
INS Verification Report
To help you monitor the status of your benefit verification attempts, you’ll have access to a report called the INS Verification Report. This report will help you know if your attempts were successful (and if not, why), and how many processed verifications you’ve had in the selected time frame.
Click here for a video walkthrough and article about the INS Verification Report.
Congratulations! You’ve learned what insurance benefit verification is, why it’s important, how to electronically verify patient insurance benefits, and plenty of tips and tricks to use along the way to electronically verify benefits in WebPT like a seasoned professional.
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