How should you verify patient eligibility before submitting a CMS-1500 claim?

• A. Verify only the patient name.
• B. Check payer policy, verify active coverage, benefits, and any requirements before submission.
• C. Submit first, then verify eligibility if denied.
• D. Eligibility is not required for CMS-1500.

Answer: (B)

Verifying eligibility before submitting a CMS-1500 claim is about confirming the patient has valid, active coverage for the services being billed and understanding the payer’s rules up front. This means checking the payer’s policy, confirming active coverage, reviewing what benefits are available (what’s covered, copays, deductibles, coinsurance), and noting any requirements such as referrals or prior authorization. Doing this before submission helps ensure the claim matches the patient’s benefits, reduces the chance of denials, and clarifies patient responsibility.

Verifying more than just the patient’s name is essential because coverage and benefits can vary widely even for the same patient. Submitting a claim before checking eligibility can lead to denials, delays, and extra work to resubmit. And eligibility is not optional; many payers require current eligibility and any applicable requirements to be known before a CMS-1500 claim is accepted.