| 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
