The eligibility check that says 'active' and still leaves you unpaid

Eligibility verification runs on a HIPAA-standard pair of transactions. You send a 270 inquiry — this provider, this patient, this date, these service types — and the payer returns a 271 response describing coverage. Clearinghouses and EHRs wrap this in a button, and for most medical specialties it works well.

What a 271 can tell you

• Whether the policy is active on the date of service.
• Plan type — HMO, PPO, EPO, Medicare Advantage, Medicaid managed care.
• Copay for the relevant service type.
• Coinsurance percentage.
• Deductible — annual amount and how much remains.
• Out-of-pocket maximum and progress toward it.
• Visit limits, where the payer reports them.
• Prior authorisation indicators.
• Coordination of benefits — whether another plan is primary.

The behavioral health carve-out problem

This is the part that catches practices, and it is structural rather than a data-quality issue.

Many plans do not administer behavioral health benefits themselves. They carve them out to a managed behavioral health organisation, and that entity holds the network, the authorisation rules, the fee schedule and the claims processing for mental health and substance use services — while the medical plan continues to handle everything else.

A 271 sent to the medical plan will frequently answer confidently about medical benefits and say little or nothing useful about the carve-out. Worse, it may return a copay that is real for a primary-care visit and wrong for a therapy session, and there is nothing in the response flagging that distinction.

What the 271 does not tell you

Even against the right entity, several things eligibility cannot answer:

• Whether you are in network for that specific plan. Network participation is contract-level and product-level, and being contracted with a payer does not mean being in every one of its products.
• Whether your licence type is covered under that plan for that service.
• Whether the specific CPT code is covered, or requires authorisation.
• Accumulator accuracy. Deductible figures lag claims in process, sometimes by weeks, so a "deductible met" response can be wrong in both directions.
• Medical necessity. Eligibility is not adjudication. An active policy tells you the client has coverage, not that this claim will be paid.

When to verify

Three points, and the second is the one most practices skip.

1. Before the first session. Obvious, and universally done.
2. Before every subsequent session, automatically. Plans change mid-year, employment ends, deductibles reset, and clients rarely think to mention any of it. A re-check 48 hours ahead of each appointment catches changes while there is still time to tell the client.
3. At the start of each plan year, when deductibles reset and benefit design changes take effect. January is the month self-pay balances surprise clients.

The economics favour automation heavily. A copay that moved from $25 to $45 and was not caught becomes a $20 balance per session that you either chase or write off, across however many sessions pass before someone notices.

What to ask when you call

For anything complex, or where the 271 is ambiguous, a phone call remains necessary. A workable script:

• Is behavioral health administered by you or carved out? If carved out, to whom?
• Is this provider in network for this specific plan and product?
• What is the copay or coinsurance for outpatient behavioral health, CPT 90837?
• Has the deductible been met, and as of what date is that figure current?
• Is prior authorisation required, and after how many visits?
• Are there annual visit limits?
• Is telehealth covered at the same rate, and are there place-of-service restrictions?

Record the representative's name, the date and the reference number. Verbal quotes are not binding on payers, but a documented reference number materially improves an appeal.

Telling the client

Verification is only useful if it reaches the person who pays. A client who learns at the desk that their copay tripled has a worse experience than one who received a message two days earlier explaining it. This is the specific thing Weft automates — benefits re-check ahead of every appointment and a change arrives with a client message already drafted.

Good faith estimates

Separately from insurance verification, federal rules require good faith estimates of expected charges for uninsured and self-pay clients. The practical shape is a written estimate provided before services begin, covering the expected course of treatment rather than a single session.

For open-ended psychotherapy this is genuinely awkward — nobody knows at intake how many sessions a course will run. The workable approach is to estimate a defined period, state the per-session rate clearly, and describe how and when the estimate would be revised. Requirements and thresholds are worth confirming against current guidance, as this area has continued to develop since it took effect.

Coordination of benefits

Where a client has more than one plan, the order matters and getting it wrong produces denials that look like coverage problems.

The primary plan pays first; the secondary considers the balance after the primary's adjudication, usually requiring the primary's remittance attached to the claim. Determination of which is primary follows rules rather than preference — for dependants covered under two parents' plans, the so-called birthday rule commonly applies, and Medicare's coordination rules depend on employment status and plan size.

The practical failure is billing the secondary first, which denies, or billing only the primary and writing off a balance the secondary would have covered. Both are avoidable by asking at intake whether any other coverage exists, and asking again annually.

Medicaid specifics

Medicaid is generally payer of last resort, meaning other coverage must be billed first. Managed Medicaid adds a further layer: the client is enrolled with a specific managed care organisation, and verifying state Medicaid eligibility without identifying the MCO produces a claim sent to the wrong entity.

Medicaid eligibility can also change month to month in ways commercial coverage does not, which makes per-session verification more than a nicety. A client eligible in March may not be in April, and the redetermination process is not something they will necessarily mention.

Recording what you were told

Verification is only as good as its record. A note in a client's chart saying "benefits verified" tells a later reader nothing and supports no appeal.

What to capture: the date, the entity checked, the source (electronic response or a named representative with a reference number), the copay or coinsurance quoted, the deductible figure and its as-of date, and any authorisation requirement. Where a payer later contradicts what you were told, that record is the whole of your argument — and where a client disputes a balance, it is the difference between an explanation and an apology.

Verified 29 July 2026. Transaction standards (X12 270/271, 835, 837) are set federally under HIPAA; coverage, authorisation requirements, timely-filing windows and appeal rights are set by individual payers and by state law, and vary by contract. Figures described as typical are illustrative, not guarantees. Primary references: CMS billing guidance; X12 code lists; HHS HIPAA. This page is billing reference, not legal or coding advice.