Purpose
To ensure every scheduled patient has active, valid insurance coverage prior to their appointment. Consistent verification prevents billing errors, reduces patient frustration, and maintains schedule efficiency.
Timing and Workflow Overview
| Stage | Action | Responsible | Notes |
|---|---|---|---|
| At Scheduling | Verify insurance coverage and upload the insurance card and photo ID. Confirm plan name and policy number match payer eligibility. | Front Office / Coordinator | Prevents future cancellations due to ineligible coverage. |
| 24 hour Prior | 1. Automated check runs in Charm. | Coordinator / Eligibility Staff | Revised to 24 hours 10/15/25 -sf |
| Daily Review | Run the Eligibility Inquiry Report (Billing → Other Reports → Eligibility Inquiry) to confirm all scheduled patients show valid, active coverage. | Coordinator / Office Manager | Cross-check against the appointment list view. Resolve any “orange clock” or “unknown” icons. |
| Weekly Review | Analytics > Patient Insurance Reports > Insurance Category: Primary > Show Policies by Termination date: Terminates in next 60 days | Coordinator | Record each attempt in Quick Notes and mark communication in chart. |
| Patient Contact | For patients with inactive or ineligible coverage: • Call up to two times. • Send one portal message requesting updated insurance. • Document all outreach. |
Coordinator | Record each attempt in Quick Notes and mark communication in chart. |
| 24 Hours Prior | Perform a final manual check for all patients with updates or unresolved eligibility. | Coordinator | Verify in payer portal if Charm returns “unknown.” |
| No Response / Inactive Coverage | If insurance remains inactive and patient has not provided updates:
• Cancel appointment and document the reason. |
Coordinator → Office Manager | Decision tree ensures consistency and transparency. |
| Day Of Visit (Check-In) | Confirm insurance card and photo ID are still current. Update any expired or missing documents before check-in is completed. | Front Desk / Coordinator | Address active alerts at this time (e.g., missing card). |
Eligibility Exceptions
Orange, / Unknown status workflow: Reach out to patient via phone (LVM)/Portal Msg/dialpad SMS.
Payer-Specific Notes
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SoonerCare / Sooner Select: Verify directly on the Oklahoma Medicaid Portal; Charm cannot confirm TPL (Third Party Liability). – need to emphasize TPL check for any OHCA based plan
- Turn into table showing which payers need manual check
Documentation Standards
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Record all patient contacts and attach screenshots when coverage verification is unclear.
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Remove resolved alerts (e.g., outdated “missing card”) and convert ongoing reminders to sticky notes to reduce alert fatigue.
Escalation and Oversight
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Unresolved cases ≥ 24 hours before appointment → Escalate to Office Manager.
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Training checks → Eligibility reports are reviewed weekly by Office Manager for completeness.
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Missed eligibility at visit → Office Manager notified for internal review.
Goal Metrics
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100% of scheduled patients checked ≥ 8 days before visit.
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0 patients seen with inactive insurance without documented self-pay agreement.
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All patient contact attempts documented in Charm.