Claims guide

Eligibility Verification: What to Confirm Before Every Mental Health Visit

Eligibility verification is the check that tells you whether a patient's coverage is active and what the plan will pay for a visit. It covers more than a yes or no on the insurance card. This guide shows therapists, psychiatrists, and billing staff what to confirm, how the electronic 270/271 check works, and how to record it.

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What eligibility verification is, and what it is not

Two checks get mixed up, and the difference costs money.

Eligibility verification answers one question: is this person covered by this plan on this date? Benefit verification goes one step further. It asks what the plan pays for the service you plan to bill. Most practices need both, and most staff do them in one call or one electronic request.

A card that was valid last year proves nothing today. Employers change plans. Members lose coverage. A plan can also move behavioral health to a different company. A claim sent to the wrong plan is rejected or denied, and the practice loses weeks. Good eligibility verification stops that before the visit.

For psychotherapists, the key questions are about session codes and visit limits. For psychiatrists, they are about evaluation and management (E/M) codes, add-on psychotherapy codes, and sometimes medication management rules. MCM South runs eligibility verification and benefit checks every week for psychotherapists and psychiatrists, and the routine below is one any office can copy.

How the 270/271 eligibility verification check works

The electronic version of eligibility verification uses a matched pair of transactions.

The 270 is the inquiry your system sends. The 271 is the plan's answer. The standards body X12 lists them as the Health Care Eligibility Benefit Inquiry and Response (X12 transaction sets, checked 10/10/26). Under HIPAA, the Centers for Medicare & Medicaid Services (CMS) lists ASC X12N 270/271 Version 5010 as the adopted standard for eligibility and benefit verification. The standard had a compliance date of January 1, 2012, and the federally mandated operating rules had one of January 1, 2013 (CMS adopted standards and operating rules, checked 10/10/26).

Operating rules add detail on how the exchange runs. CAQH CORE, the group HHS designated to write them, publishes the Eligibility & Benefits rule set, including an infrastructure rule (vEB.2.0) and a data content rule (vEB.2.1). It describes its requirements as a floor, not a ceiling (CAQH CORE operating rules, checked 10/10/26). Your clearinghouse or practice management system handles the technical side. You need to know what comes back and what to do with it.

Private plans

Most private plans accept the 270 through a clearinghouse, a payer portal, or both. Answers vary. One plan may return copay, coinsurance, and deductible detail. Another may return only active or inactive status. Read the 271 carefully and call the plan when a field is blank. Our private insurance guides point to how each major plan handles checks.

Medicare

CMS runs the HIPAA Eligibility Transaction System (HETS) so users can check Medicare eligibility in real time. Submitters send a 270 and get a 271. The system supports real-time transactions only, not batch files, and it is typically available around the clock (CMS HETS, checked 10/10/26). Submitters need their own tool, or a vendor's, to build 270 requests and read 271 responses, and third-party vendors must be enrolled. Ask your clearinghouse or software vendor how your practice connects.

Medicaid and state programs

Medicaid eligibility is state-run, and each state sets its own portal and rules. Many Medicaid members are in managed care plans, so the plan on the card may not be the state agency. Never apply one state's process to another. Use the state Medicaid agency's provider manual and the managed care plan's portal for the state you bill.

Seven checks that make eligibility verification complete

Run the same seven checks on every new patient and every plan change.

Seven checks for eligibility verification in a behavioral health practice
Check	What to confirm	Why it matters
1. Coverage active	Plan name, member ID, and coverage dates	A lapsed plan means a rejected claim
2. Behavioral health network	Whether mental health runs through a separate company	The claim goes to the right payer
3. Your network status	In-network or out-of-network for your specific provider	Changes the rate and the patient share
4. Cost share	Copay or coinsurance, and deductible met so far	Sets what you collect at the visit
5. Visit limits	Annual or lifetime session caps, if any	Prevents billing past a cap
6. Authorization	Whether the service or code needs prior approval	Missing auth is a common denial
7. Other coverage	A second plan, Medicare, or another payer	Sets the order for claims

Write the date, the time, the name of the person you spoke with, and the reference number. If the plan gave an answer by phone, that note is your proof. A missing note is a weak appeal. For the terms behind these fields, see our reimbursement terms glossary.

Mental health details that general eligibility verification misses

A generic medical check often skips the fields that matter most to behavioral health.

Out-of-network benefits

If you are out of network, ask whether the plan has out-of-network benefits at all, what it will treat as the allowed amount, and whether the out-of-network deductible is separate. Plans differ, and some have none. Read more in our guide to in-network versus out-of-network credentialing.

Copay versus coinsurance

A copay is a fixed dollar amount. Coinsurance is a percentage of the allowed amount. Mixing them up leads to wrong collections. Ask which applies to each code you bill, because a plan can charge different amounts for therapy and for medication management visits.

Deductible, visit limits, and authorization

Ask how much of the deductible is met and when the plan year resets. Ask whether sessions are capped and whether the count is shared across providers. Ask which codes need authorization, including add-on codes billed with psychiatric E/M visits. Do not guess from a prior patient on the same plan, since employer groups set their own rules. Psychiatrists should also ask whether E/M visits and add-on psychotherapy codes fall under the same behavioral health benefit, and whether telehealth visits are covered the same way. Therapists should ask the same about telehealth sessions. Write each answer down. Keep what you learn next to your credentialing records so network status stays current.

What should eligibility verification confirm before a first therapy visit?

Here is the short version for new patients.

Short answer: Eligibility verification should confirm active coverage, the correct behavioral health payer, your network status, copay or coinsurance, remaining deductible, visit limits, and any authorization rule. Add a check for other coverage. Record who you spoke with and when, so you can prove what the plan said if a claim is denied.

If the answer is unclear, treat it as unverified. Tell the patient what you could confirm and what you could not, and do not promise a cost you cannot support. Billing questions that start here often end in an appeal, which our claim denials and appeals pages explain.

When to run eligibility verification, and what to record

One check at intake is not enough.

Run eligibility verification before the first visit, and again whenever something changes. Good triggers for repeat eligibility verification are a new plan year, a new card, a change in the patient's job, a denial that cites coverage, and a long gap between visits. Payer contracts may set their own rules, so check yours, then set a schedule that fits your caseload and write it down.

Keep the record in the patient's billing file, not in a staff member's head. Include the source (portal, 271, or phone), the date, and the answers to the seven checks. When the benefit changes mid-year, add a new note instead of overwriting the old one. See how this fits into a full practice management routine, and review claims processing terms if your team is new to billing.

What to do Monday morning

Pick the three changes that cost the least.

List every patient seen this month and mark the date of their last eligibility verification.
Re-run eligibility verification for anyone with no check on file or a check from before the plan year changed.
Add the seven checks to a one-page intake form so every eligibility verification call gets the same answers.
Ask your clearinghouse which payers return a full 271 and which need a phone call.
See the practices we serve, then flag any of the seven checks your office has never asked for.

Frequently asked questions

What is eligibility verification?

Eligibility verification is the check that confirms a patient's coverage is active on the date of service. A full check also covers benefits: copay or coinsurance, deductible, visit limits, authorization rules, network status, and other coverage.

What are the 270 and 271 transactions?

The 270 is the electronic eligibility request your system sends to a plan. The 271 is the plan's response. Both follow the ASC X12N Version 5010 standard that CMS lists as adopted under HIPAA.

Does eligibility verification guarantee payment?

No. Eligibility verification shows what the plan reported on that date. Claims can still be denied for medical necessity, coding, authorization, or coverage changes. Keep your notes and the reference number in case you need to appeal.

How is Medicare eligibility checked?

CMS runs the HIPAA Eligibility Transaction System, which accepts real-time 270 requests and returns 271 responses. Submitters need a tool, their own or a vendor's, that builds the 270 and reads the 271. Ask your software vendor how your practice connects.

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