What are some questions to ask when verifying insurance coverage and benefits?


When calling insurance companies, knowing what to ask before you call is essential.

The insurance card provides a number to contact for benefits and eligibility.  Ensure you have a clear picture of the insurance card front and back.  I use websites for some information; however, they may not give you complete coverage and benefit information.


1) Verify the patient’s name as listed with the insurance company.  The name on the claim should match what the insurance company has.

2) Is the coverage active?

3) What are the coverage dates

4) Does the patient have other insurance as primary or secondary?

5) Are there copayments for the services?

6) What is their copayment amount?

7) Is this policy a medical, dental, or vision policy?

8)  Is the plan an HMO, PPO, EPO, Christian sharing ministry, indemnity, etc.?

9) What is the deductible amount?  How much has been met?

10) Is there a coinsurance percentage?

11) Is there an out-of-pocket amount?  How much has been met?

(Make sure to ask these questions for in-network and out-of-network, depending on your status with the insurance company)

12) Has the insurance plan reached its annual or lifetime maximum?

13) If the patient is pregnant, ask if the patient is covered for maternity benefits.

14) If the patient is pregnant, ask if the newborn will be covered under this policy.

15) Are there any pre-authorizations or referrals required?

(Have your codes available for the pre-authorization check)

16) If a referral is required, ask for the PCP information to contact them.

17) Does the policy have any pre-existing conditions?

18) Is the patient in a waiting period before the coverage is active?

19) What is the billing address and payor ID to send claims to?


This is a suggested list of questions for you to ask the insurance companies.  Each practice will have different needs when calling the insurance company.   Feel free to use these questions and tailor them to your practice.