eligibility-and-claims

name	eligibility-and-claims
description	Run the eye-care claims loop: verify both medical and vision eligibility before the visit, manage payor mix, and triage denials by cause (eligibility, coding/medical-necessity, wrong-payor-routed, timely-filing). Payor specifics are verify-at-use.

Eligibility & Claims

Close the loop from benefit check to clean claim to resolved denial.

Advisory, not billing advice. Payor rules, timely-filing windows, and eligibility response formats vary by payor and change — [verify-at-use]. No PII/PHI; work in patterns and policy.

Verify eligibility before the visit

The single highest-yield fix for collection failures is knowing the benefit before the patient arrives, not at check-in. Check both medical and vision benefits at scheduling because the visit may route either way (see ../medical-vs-vision-billing/SKILL.md).

Step	When	Catches
Medical + vision benefit check	At scheduling	No-benefit surprises, exhausted allowances, wrong plan on file
Re-confirm at check-in	Day of	Plan changes since scheduling

Read the payor mix

Know the share of visits/revenue by payor and the effective reimbursement by plan. The mix is a strategy lens, not a line you discover in adjustments.

Triage denials by cause

Group denials, then fix the process that produced the group:

Denial cause	Fix the process
Eligibility / no benefit	Pre-visit eligibility step (above)
Coding / medical necessity	Code to the encounter; document necessity
Wrong payor routed (medical vs vision)	The routing decision (separate skill)
Timely filing	Submission cadence + worklist

Anti-patterns

• Discovering eligibility at checkout instead of at scheduling.
• Working denials one-by-one instead of by cause cluster.
• Treating payor mix as an accident rather than a managed lens.

See also

• ../medical-vs-vision-billing/SKILL.md; traverse the claim denial triage tree in ../../knowledge/eyecare-practice-decision-trees.md.
• Best practices: ../../best-practices/verify-eligibility-before-the-visit.md.
• Shared revenue-cycle mechanics: ../../../medical-revenue-cycle/CLAUDE.md.