Lesson · Lesson 2 of 5
Eligibility and pre-authorisation
- MI-04Perform an eligibility check and decide proceed / pre-auth / self-pay
Checking before, not arguing after
An eligibility check asks one narrow question: on the date this service will be delivered, is there active coverage that would pay for it? It is cheap to ask beforehand and expensive to discover afterwards.
Pre-authorisation asks a second, different question: even if coverage is active, does this payer require permission before this particular service? Confusing the two is the most common error here. Active coverage is not permission.
Whether coverage is active for this member, on this date, for this category of service. It is a question about the policy, not about the patient's condition.
Permission obtained from the payer before delivering a specific service. Its absence can make an otherwise valid claim unpayable, and it usually cannot be obtained retroactively.
Training example: a policy is active from 1 February, and the payer requires pre-authorisation for imaging. Both must be true before imaging is delivered.
- Identify the memberMatch the person to a policy using the card, not memory.
- Confirm the dateCoverage is a period, not a state. Ask about the service date.
- Confirm the service categoryActive coverage does not mean everything is covered.
- Check for a pre-authorisation requirementA separate question with a separate answer.
- DecideProceed, obtain pre-authorisation first, or convert to self-pay.
- Record what you were toldA reference number turns a claim into an argument you can win.
Key takeaways
- Eligibility asks whether coverage is active on the service date; it is a question about the policy.
- Pre-authorisation is a separate question, and active coverage is not permission.
- The three honest outcomes are proceed, pre-authorise first, or convert to self-pay.
- A recorded reference number is what makes a later dispute winnable.
Three honest outcomes, worked through
A member is booked for imaging next Tuesday. The eligibility response shows the policy is active on that date, and this payer requires permission before imaging.
A patient arrives for a planned procedure. The eligibility check returns no active coverage for today's date. The patient insists the policy was renewed last week.
Knowledge check — not scored
Coverage is active on the service date. What does that tell you about pre-authorisation?
Select one answer.
Knowledge check — not scored
A member arrives for a routine consultation today. The eligibility response shows their coverage lapsed last month; they tell you they mean to renew this week. What do you do?
Select one answer.