Insurance Eligibility Verification & Prior Authorization

Why front-end verification matters so much in OB/GYN

When people think about denials, they usually picture coding errors. But in many OB/GYN practices, the most expensive problems start before the patient is even seen:

• The patient's employer plan changed in January and nobody updated the insurance on file.
• A Medicaid patient's coverage moved to a different managed care plan mid-pregnancy.
• The patient has two policies and the primary/secondary order was entered backwards.
• A hysterectomy was scheduled and performed, but the authorization was never obtained — or was obtained for a different CPT code.
• An IUD was inserted for a patient whose plan requires the device to come from a specialty pharmacy.

None of these are fixed by better coding. They're fixed by verifying coverage and requirements before the service, which is what this service does. After more than eight years in OB/GYN billing, we've seen how much revenue a consistent front-end process protects.

What we verify

Eligibility and coverage

• Active coverage on the date of service
• Correct payer, plan and member ID (including Medicaid managed care plan assignment)
• Coordination of benefits — primary, secondary and tertiary order
• Network status for the rendering provider and location

Benefits for the planned services

• Office visit copays, deductibles and coinsurance
• Preventive vs. diagnostic benefits for well-woman visits, Pap tests and screenings
• Prenatal care, ultrasound limits and delivery coverage
• Contraception and LARC coverage, including device sourcing rules
• Surgical benefits, facility network status and out-of-pocket estimates
• Fertility benefits, which are often limited or excluded — see infertility billing

Prior authorization management

We identify which services require authorization for each payer, submit requests with the clinical documentation payers ask for, follow up until a decision, and record the authorization number, approved codes, units and date range. Services we commonly authorize for OB/GYN practices:

When a procedure changes in the operating room, we request authorization updates within the payer's window — one of the most common sources of avoidable surgical denials.

The pregnancy re-verification workflow

Obstetric care spans months, and coverage can change at any point. Our approach:

1. First prenatal visit: full eligibility and maternity benefit verification, payer notification if required.
2. During the pregnancy: coverage re-verified at set points (for example, each trimester) and whenever the patient reports a change.
3. Before delivery: final verification so the delivery and postpartum care are billed to the right plan.
4. If coverage changed: billing is split appropriately — see global maternity billing for how split care is handled.

Patient cost estimates

Patients increasingly expect to know what they'll owe — and clear estimates reduce bad debt. Once benefits are verified, we provide your staff with a simple summary they can share: what the plan covers, the patient's estimated responsibility, and what to collect at the visit. For self-pay patients and certain services, federal good-faith-estimate rules may apply; we can help your team understand when.

How we fit into your workflow

• We work from your schedule in your practice management system — no separate portal for your staff to learn.
• Verification results and authorization details are documented in the patient's account.
• Problems (inactive coverage, missing authorization, out-of-network provider) are flagged to your front desk before the appointment so they can contact the patient.
• Urgent same-day additions are handled as they come in.

Results you can measure

We track front-end denial categories — eligibility, coordination of benefits, authorization and registration — as part of our monthly reporting. Watching those categories shrink is the clearest sign the process is working. We'll show you your starting point from the free audit so you can compare. See denial management for how we handle the denials that do get through.

Part of full-service OB/GYN billing

Eligibility verification is available on its own or as part of our complete revenue cycle management service. Either way, the people verifying your coverage understand OB/GYN billing, so they know which benefits actually matter for a prenatal visit, a delivery or a surgical case.

A day in the life of verification

Here's what verification looks like for a typical OB/GYN schedule:

• 48–72 hours before appointments, the next days' schedule is pulled and each patient's coverage is checked electronically through payer eligibility transactions and, where needed, payer portals or phone calls.
• New patients and new pregnancies receive a full benefit breakdown: deductible and out-of-pocket status, maternity coverage, ultrasound limits and any notification requirements.
• Surgical bookings trigger an authorization check matched to the planned CPT codes, the facility and the date range. If an authorization is required, the request goes out with the clinical notes the payer asks for.
• Exceptions — inactive coverage, a plan change, a missing referral, an out-of-network provider — are flagged to your front desk with a clear note of what to ask the patient.
• Same-day add-ons are verified as they appear on the schedule.

By the time the patient checks in, your team knows what to collect and whether there's anything to resolve.

Medicaid and pregnancy coverage

Medicaid covers a large share of US births, and pregnancy-related Medicaid has its own rules. Many states offer presumptive eligibility for pregnant patients while a full application is processed, and most have extended postpartum Medicaid coverage to 12 months. Patients may also move between fee-for-service Medicaid and a managed care plan during the pregnancy. Each of these changes who should receive the claim. We verify Medicaid status and plan assignment carefully, document the effective dates, and coordinate with billing so antepartum, delivery and postpartum services go to the right payer.

Common front-end denials verification prevents

Get a free front-end denial review

Message us on WhatsApp. We'll look at a sample of your recent denials and show you which ones were caused by eligibility, coordination of benefits or authorization problems — and what a verification process would have caught. No forms, no cost.