Real-Time Eligibility

The agency's system sends a 270 eligibility inquiry with the patient's identifying information and receives a 271 response describing coverage: plan type, effective dates, and benefit details. For Medicare, the authoritative source is HETS, the HIPAA Eligibility Transaction System, which returns fee-for-service status, Medicare Advantage (MA) enrollment with the plan name, hospice election status, and home health episode information including whether another agency has an open period. Commercial and Medicaid checks run through payer-specific connections or clearinghouses. The whole exchange takes seconds, which is why it belongs at the front of intake rather than after the referral is accepted.

A useful eligibility check answers specific questions, not just is the patient covered:

• Is the patient enrolled in traditional Medicare or a Medicare Advantage plan, and which plan?
• Has the patient elected hospice, which changes what home health can bill?
• Does another agency have an open home health period, which affects transfer handling and payment?
• Are Medicare Part A and B both active, and what are the effective dates?
• For MA and commercial plans, does home health require prior authorization?

Each of these, missed at intake, becomes a denial or a compliance problem weeks later.

Eligibility is not static. Patients switch between traditional Medicare and MA plans during enrollment periods, elect hospice mid-episode, or lose Medicaid coverage at redetermination. An eligibility check run once at referral and never again will miss these changes. Strong agencies verify at referral, again at or just before the start of care, and then on a recurring monthly cycle for patients on census, with special attention around January 1 when MA plan changes take effect. Catching an MA switch in December for a January recertification means the difference between a managed care authorization done on time and 30 days of unbillable visits.

The predictable failures: accepting a referral labeled Medicare that turns out to be a Medicare Advantage plan the agency is not contracted with; missing an open episode at another agency and losing the payment dispute; not seeing a hospice election and billing home health services the hospice benefit covers; and running checks with mistyped Medicare Beneficiary Identifiers that return false negatives. Process fixes are simple: make a clean 271 response a hard gate before scheduling the start of care, route ambiguous responses to a senior biller, and log every check so there is an audit trail showing what the agency knew and when.