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?

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?

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?

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?

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?

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

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

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