coverage-verification-checker

# Coverage Verification Checker

## Overview

Deterministic verification of patient insurance coverage. Each check returns a binary result—proceed, stop, or action required. This skill provides the decision logic for go/no-go coverage decisions before service.

## Verification Workflow

```
┌─────────────────────────────────────────────────────────────────┐
│                  COVERAGE VERIFICATION                          │
├─────────────────────────────────────────────────────────────────┤
│                                                                 │
│  INPUT: Patient, Insurance, Provider, Service, DOS              │
│                                                                 │
│  ┌──────────┐    ┌──────────┐    ┌──────────┐    ┌──────────┐  │
│  │ CHECK 1  │ →  │ CHECK 2  │ →  │ CHECK 3  │ →  │ CHECK 4  │  │
│  │ Active?  │    │ Dates?   │    │ Network? │    │ PCP/Ref? │  │
│  └────┬─────┘    └────┬─────┘    └────┬─────┘    └────┬─────┘  │
│       │               │               │               │         │
│       ▼               ▼               ▼               ▼         │
│      FAIL →────────────────── STOP ──────────────────────→      │
│       │                                                         │
│      PASS ─────────────────────────────────────────────→        │
│                                                                 │
│  ┌──────────┐                                                   │
│  │ CHECK 5  │                                                   │
│  │ Auth?    │ → If required → Route to prior-auth-navigator    │
│  └────┬─────┘                                                   │
│       │                                                         │
│       ▼                                                         │
│   ✓ PROCEED                                                     │
│                                                                 │
└─────────────────────────────────────────────────────────────────┘
```

## The Five Checks

### Check 1: Coverage Active

**Question:** Is the patient's insurance currently active?

| Response | Result | Action |
|----------|--------|--------|
| Active | ✓ PASS | Continue to Check 2 |
| Inactive | ✗ STOP | See inactive coverage workflow |
| Pending | ⚠ HOLD | Verify effective date, may need to wait or reschedule |

**Inactive Coverage Workflow:**
```
1. Verify with patient — Did coverage change?
2. Check for alternate insurance
3. Check COBRA eligibility (if recently termed)
4. Check for retroactive eligibility (Medicaid)
5. If no coverage → Self-pay workflow
```

### Check 2: Effective Dates

**Question:** Is date of service within coverage effective dates?

| Scenario | Result | Action |
|----------|--------|--------|
| DOS within effective dates | ✓ PASS | Continue |
| DOS before effective date | ✗ STOP | Reschedule or self-pay |
| DOS after term date | ✗ STOP | Check for new coverage |
| Coverage pending (future effective) | ⚠ HOLD | Reschedule to effective date |

**Edge Cases:**
- **Newborn:** Coverage may be retroactive to birth
- **Medicaid:** Often retroactive to application date
- **COBRA:** 60-day election period, retroactive if elected

### Check 3: Provider Network Status

**Question:** Is the rendering provider in-network for this plan?

| Status | Result | Action |
|--------|--------|--------|
| In-network | ✓ PASS | Continue |
| Out-of-network | ⚠ WARN | Inform patient of higher cost, get consent |
| Not contracted | ⚠ WARN | Verify OON benefits exist |
| Tier 2/3 network | ⚠ INFO | May have higher cost share |

**Out-of-Network Decision:**
```
IF out-of-network:
  1. Check if plan has OON benefits
  2. Calculate patient cost differential
  3. Inform patient in writing
  4. Get signed consent before service
  5. Consider: Refer to in-network provider?
```

### Check 4: PCP / Referral Requirements

**Question:** For HMO/managed care—is referral required and on file?

| Plan Type | PCP Required | Referral Required |
|-----------|--------------|-------------------|
| HMO | Yes | Yes (for specialists) |
| POS | Yes | Yes (for in-network benefits) |
| PPO | No | No |
| EPO | No | Sometimes |

**Decision Logic:**
```
IF plan_type IN (HMO, POS):
  IF service_provider = PCP:
    PASS (no referral needed)
  ELSE:
    CHECK referral on file
    IF referral exists AND covers service AND DOS in range:
      PASS
    ELSE:
      STOP — Referral required
```

**Missing Referral Workflow:**
```
1. Contact PCP office for referral
2. Verify referral covers:
   - Specific provider
   - Service type
   - Date range
   - Number of visits
3. Document referral number
4. Proceed once obtained
```

### Check 5: Authorization Required

**Question:** Does this service require prior authorization?

| Result | Action |
|--------|--------|
| No auth required | ✓ PROCEED |
| Auth required, on file | ✓ PROCEED (verify auth covers service) |
| Auth required, not on file | ⚠ ROUTE to prior-auth-navigator |
| Auth denied | ✗ STOP — Do not proceed without resolution |

**Auth Verification:**
```
IF auth on file:
  VERIFY:
    - Auth number valid
    - Covers requested CPT
    - DOS within auth dates
    - Units/visits remaining
  IF all valid:
    PASS
  ELSE:
    Need new/modified auth
```

## Output Structure

```
VERIFICATION RESULT
───────────────────
Patient: {name}
DOS: {date}
Provider: {provider}
Service: {cpt} - {description}

CHECK RESULTS:
[✓] Coverage Active: Active through {term_date}
[✓] Effective Dates: DOS within coverage period
[✓] Network Status: In-network
[✓] PCP/Referral: Referral #{ref_num} on file
[✓] Authorization: Not required

RESULT: ✓ PROCEED
───────────────────
```

**Or if issues:**

```
VERIFICATION RESULT
───────────────────
Patient: {name}
DOS: {date}

CHECK RESULTS:
[✓] Coverage Active: Active
[✓] Effective Dates: Valid
[✗] Network Status: OUT OF NETWORK
[—] PCP/Referral: N/A (PPO)
[⚠] Authorization: Required, not on file

RESULT: ⚠ ACTION REQUIRED

ACTIONS NEEDED:
1. Inform patient of out-of-network status
   - In-network cost: ~${in_network_estimate}
   - Out-of-network cost: ~${oon_estimate}
   - Get signed consent
2. Obtain prior authorization
   - Route to: prior-auth-navigator
   
───────────────────
```

## Coordination of Benefits (COB)

When patient has multiple coverages:

### Determining Primary Payer

| Rule | Primary Is |
|------|------------|
| **Birthday Rule** (dependents) | Parent with earlier birthday in calendar year |
| **Active vs. COBRA** | Active employment coverage |
| **Active vs. Retiree** | Active employment coverage |
| **Longer vs. Shorter** | Coverage in effect longer |
| **Medicare + Employer** | Depends on employer size and situation |

### COB Workflow

```
1. Identify all coverages
2. Determine primary using rules above
3. Verify primary first
4. Note secondary for claim submission
5. Document COB in PM system
```

## Edge Case Handling

### Pending Coverage

```
IF status = "pending":
  CHECK enrollment_effective_date
  IF effective_date <= DOS:
    RECOMMEND: Wait for coverage to activate
    ALTERNATIVE: Collect deposit, reconcile later
  ELSE:
    RECOMMEND: Reschedule to after effective date
```

### Retroactive Termination

```
IF termed_date < today AND termed_date > last_verified:
  ALERT: Coverage terminated since last check
  ACTION: 
    - Check for new coverage
    - If no new coverage, initiate self-pay
    - Review any unbilled services in term gap
```

### Medicare as Secondary

```
IF patient_has_medicare AND patient_has_employer_coverage:
  IF employer_size >= 20 employees:
    PRIMARY: Employer coverage
    SECONDARY: Medicare
  ELSE:
    PRIMARY: Medicare
    SECONDARY: Employer coverage
```

### Workers' Comp / Auto / Liability

```
IF injury_related:
  CHECK: 
    - Workers' compensation claim?
    - Auto accident (PIP/MedPay)?
    - Third-party liability?
  IF yes:
    Primary billing to WC/Auto/Liability
    Health insurance is payer of last resort
```

## Verification Timing

| Timing | Purpose |
|--------|---------|
| **Scheduling** | Catch issues early, time to resolve |
| **24-48 hrs before** | Confirm no changes |
| **Day of service** | Final verification for high-value services |
| **Each visit** | For ongoing care (coverage can change) |

## Resources

### references/
- **payer-template.md** — Template for payer-specific verification rules
- **cob-rules.md** — Detailed coordination of benefits rules
- **plan-type-guide.md** — HMO/PPO/EPO/POS characteristics

### scripts/
- **verification-checker.py** — Runs verification checks

### assets/
- **oon-consent-form.docx** — Out-of-network consent template