eligibility-verification

name	eligibility-verification
description	Use when a provider needs to verify patient insurance eligibility, check active coverage status, determine benefits and cost sharing (copay, coinsurance, deductible), or assess whether a service requires prior authorization.

Eligibility Verification

When to use this skill

• Verify if a patient has active insurance coverage
• Check coverage effective dates and plan details
• Determine benefits for a specific procedure or service
• Calculate patient cost sharing (copay, coinsurance, deductible)
• Determine if prior authorization is required for a service
• Retrieve patient demographics from HealthLake

MCP Servers Used

• AgentCore Gateway — for HealthLake tools (FHIR R4 patient data, coverage, and clinical records)

Workflow: Verify Patient Eligibility

Step 1: Patient identification

Tools via Gateway:

• advanced_patient_search — search by demographics (name, DOB, member ID)
• get_patient_everything — comprehensive patient record retrieval

Verify:

• Patient identity matches request (name, date of birth, member ID)
• Correct patient record is selected (avoid wrong-patient errors)

Step 2: Coverage verification

Retrieve from HealthLake Coverage resources:

• Insurance plan name and type (commercial, Medicare, Medicaid, Tricare)
• Payor organization name and ID
• Group number and subscriber ID
• Coverage effective dates (start and end)
• Coverage status (active, cancelled, entered-in-error)

Deterministic auto-populate: the app's /patients?q=<id> API resolves demographics and active Coverage (payer + member ID) and conditions in a single fast FHIR call. Prefer this for pre-filling intake fields rather than asking the model to parse free text. The agent is still the source of truth for the eligibility assessment.

Decision: If coverage is NOT active → stop and report to provider with recommended next steps.

Step 3: Benefits check

Determine for the requested service:

• Is the service a covered benefit under the plan?
• Are there benefit limitations or exclusions?
• Remaining benefit amounts (visit limits, dollar caps)
• Network status of the requesting provider (in-network vs out-of-network)

Step 4: Cost sharing details

Calculate patient financial responsibility:

• Copay: fixed amount per visit/service
• Coinsurance: percentage patient pays after deductible
• Deductible: amount met vs remaining for the year
• Out-of-pocket maximum: amount met vs remaining
• Estimated total patient responsibility for the service

Step 5: Prior authorization determination

Check:

• Does this service/procedure require prior authorization?
• Is there an existing prior auth on file for this service?
• What are the prior auth requirements if needed?
• Recommend proceeding with prior auth workflow if required

Step 6: Summary and next steps

Present structured eligibility verification:

• Coverage status (active/inactive, plan type, dates)
• Benefits determination (covered/excluded/limited)
• Cost sharing breakdown
• Prior auth requirement (yes/no, requirements if yes)
• Clear recommendation: proceed, obtain prior auth, or contact payor

Tool Reference

Tool	Use Case	Key Parameters
get_patient_conditions	Diagnoses and conditions	patient_id
get_patient_medications	Current medications	patient_id
get_patient_observations	Lab results, vitals	patient_id
get_patient_allergies	Allergy records	patient_id
get_patient_appointments	Scheduled/past visits	patient_id
get_patient_everything	Full patient record	patient_id
advanced_patient_search	Find patient by demographics	name, dob, member_id

Key Conventions

• Always retrieve actual patient data from HealthLake — never assume coverage status
• Clearly distinguish between verified data and estimated information
• If coverage data is unavailable in HealthLake, recommend a real-time 270/271 eligibility transaction with the payor
• Follow HIPAA guidelines — minimize PHI exposure in responses
• Coverage status can change daily — verification is point-in-time
• Some plans have separate deductibles for in-network vs out-of-network