Benefits verification and prior authorization

Last reviewed November 3, 2026 · Educational use only

Most denials are decided before the patient arrives. A complete verification tells the office whether the service is covered, whether it needs approval, and what the patient will owe.

Verification checklist

Check items off as you go. The list resets when the page reloads; it is a worksheet, not a record.

Call script

For phone verification when the portal or 271 response is not specific enough. Copy it into your notes template.

Payer / plan name:                Phone / portal used:
Representative name:              Reference number:          Date/time:

1. Is the member active on the date of service? Effective and term dates?
2. Plan type (HMO/PPO/EPO/POS) and funding (fully insured or self-funded)?
3. Is our provider (NPI ______, TIN ______) in network for this plan?
4. Benefits for CPT/HCPCS ______ with diagnosis ______ in place of service __:
   - Deductible (individual / family), amount met so far?
   - Coinsurance or copay? Out-of-pocket max and amount met?
   - Out-of-network benefits, if we are not participating?
5. Is prior authorization or a referral required? Who submits it and how?
6. Any frequency limits, age limits, or exclusions for this service?
7. Is there other coverage on file (coordination of benefits)?
8. Timely filing limit and claim submission address / payer ID?
9. For out-of-network: is a gap exception available? Who pays (provider or member)?

Verification is not a guarantee of payment. Payers say so on every call; record the reference number anyway, since it supports appeals when a rep's answer was wrong.

Prior authorization

1. Find out if it is required from the payer's prior authorization list or tool, by CPT/HCPCS code. Medicare Advantage and Medicaid managed care plans require it far more than Original Medicare.
2. Gather clinical documentation that meets the payer's medical policy criteria: diagnosis, history, prior treatments tried, test results, the ordering clinician's notes.
3. Submit through the portal, the X12 278, fax or a payer's electronic prior authorization tool. Include all codes, units, place of service and dates.
4. Track the decision. Urgent requests are decided faster than standard ones. Record the authorization number, approved codes, units and the valid date range.
5. If denied, ask for a peer-to-peer review between the ordering clinician and the plan's medical director, then appeal in writing.
6. Put the authorization number on the claim (CMS-1500 box 23 / 837P REF*G1) and make sure the service matches what was approved.

Medicare: Advance Beneficiary Notice

For Original Medicare, if you expect Medicare to deny a usually-covered service as not reasonable and necessary (frequency limits, unsupported diagnosis), give the patient the ABN (form CMS-R-131) before the service. Without a valid ABN, you generally cannot bill the patient when Medicare denies.