How to do an Eligibility Estimate

When you use Healthy Bytes and request an eligibility estimate, here's how we get you the summary of benefits.

If you still do your own eligibility estimates, this guide will break down the components. Read on...

Eligibility estimates are important tools to help you get reimbursed by insurance companies! They're how you know from the get-go if your patient is covered by his plan for your nutritional counseling services. 

We covered some useful terms in a previous post on Insurance Terminology, so if this post sounds like it's full of jargon, you can use that as a reference.

What is an eligibility estimate? 

It's when you estimate the services that your patient's health insurance company covers. In the case of a dietitian, you're checking to see if the patient's plan covers nutrition counseling services and any additional diagnosis codes you may be given. 

As the agent will tell you, an eligibility estimate isn't a guarantee of coverage, but you can generally feel comfortable accepting what you learn as true. Make sure you get a reference number, though, in case you need to contest a denial.

What's in an eligibility estimate? 

After what seems like hours spent dancing to hold music, you'll be connected to a representative who'll give you specific information for nutrition counseling benefits. Here's what's typically asked and how it applies to your patient's benefits:

  1. Is there a deductible? This is important because 1) If there isn't, then the patient won't need to pay a specific amount before being covered by insurance for services or 2) If there is, then you need to know how much has been applied towards the total amount. If it's already met, chances are your patient will be covered for that service date.
  2. Is there an out-of-pocket max? This information is another amount that the patient may need to reach before their coinsurance kicks in. 
  3. Any there additional co-payments or coinsurance? Co-payments may be required at each office visit along with the deductible or after the deductible has been met. A lot of the time, after the co-pay, the patient will be covered 100% for services. Coinsurance is the amount of the service that the insurance company covers- it usually applies after the deductible and out-of-pocket max have been met. 
  4. Is a referral from a primary care provider required? This just means that your patient may need a form from their primary provider giving the okay to see you for speciality services. 
  5. Are there diagnosis restrictions? Essentially, you're asking: is nutrition counseling or another nutrition-related diagnosis (diabetes, obesity, eating disorders, etc.), along with the procedure codes covered by the plan. 
  6. Is there a maximum number of visits allowed? This is to learn if there are restrictions on how many visits a patient can have covered by insurance in the contract year. 
  7. What's the reference number for this call? In case the claim gets denied and you need to appeal it, a reference number will help you reference the information you were told on this call.

Ready For More?

When you're ready to apply this knowledge and test your skills, check out this post with some sample eligibility estimate scenarios.