Verification of Benefits

Index

1. VOB Workflow

   1. Step 1: Collect & Verify Member Information

   2. Step 2: Locate the Correct VOB Form

   3. Step 3: Investigate the Procedure & Diagnosis

   4. Step 4: Collect Provider Information

   5. Step 5: Reference Policy Documents

   6. Step 6: Provide Benefits

2. VOB Scripts

   1. Determining Procedure

   2. Determining Diagnosis

   3. Verifying Disclaimer

   4. Providing Pre-Existing Condition Limits

   5. Pre-Notification Requirements

   6. Communicating Findings

3. Documenting and Closing the Ticket
4. Advanced Benefits, Exclusions, Policies and Forms

Workflow

Step 1: Collect & Verify Member Information

• Request the member ID and date of birth.

• Check eligibility in AI before proceeding. If the member is terminated, benefits do not need to be provided.

Step 2: Locate the Correct VOB Form

• In AI, the bottom of the screen shows the policy the member has.

• Match this policy name to the VOB form in Contact Management.

Step 3: Investigate the Procedure & Diagnosis

This is the most important step to ensure accurate benefits.

• Request the procedure and diagnosis.

• Ask clarifying questions to determine exclusions.

Examples of clarifying questions:

• What kind of specialist will the member be seeing?

• Is this a screening or a diagnostic test? (important for colonoscopy, mammogram, and bloodwork)

• Is this a sick visit or a well visit?

• What is the diagnosis or chief complaint?

Step 4: Collect Provider Information

• Complete the top portion of the VOB form.

• Request:

  • Provider’s name

  • Office name

  • Tax ID number

  • Other required provider details

Step 5: Reference Policy Documents

• Pull up the following:

  • Certificate of Insurance (COI)

  • Schedule of Benefits (SOB)

  • State riders

• Open the Benefits tab in AI.

Step 6: Provide Benefits

• Use the documents above to confirm coverage.

• Include all relevant exclusions, waiting periods, and pre-existing limitations.

VOB Scripts

Determining Procedure

• Ask:

  “What benefits are you specifically needing today? Could I get a description of the service codes?”

• Check: SOB for eligible expenses, dollar amounts, and visit limits.

Determining Diagnosis

• Ask:

  “Great, thank you. And what diagnosis is this related to? Or do you have a chief complaint?”

• Check: Certificate of Insurance and state riders.

• Double-check for:

  • Exclusions

  • Waiting periods

  • State-mandated preventive care

If service not listed:

• Diagnostic services: subject to deductible/coinsurance

• Preventive services: not covered

Verifying Disclaimer

• Ask every call:

  “Did you hear the disclaimer at the beginning of the call?”

Providing Pre-Existing Condition Limits

• State every time you provide benefits:

  “If this treatment ends up being related to a pre-existing condition, the member does have a $___ limit for the coverage period. Otherwise, the member’s benefits will be…”

Pre-Notification Requirements

• Correct language:

  “So for this policy, we actually don’t pre-authorize or pre-certify, but the Health Care Management department will be able to assist you with pre-notification.”

Communicating Findings

Exclusions

• Say:

  “It looks like there are a few exclusions that may apply to that service/diagnosis. I’m going to go ahead and read them to you. The first one says…”

• Then clarify:

  “If the services or diagnosis fall within those exclusions, the claims would be denied. Otherwise, the member’s benefits will be…”

Waiting Periods

Say:

“For the services you provided, the member does have a waiting period of ______ before that would be considered an eligible expense.”

Documenting the conversation and closing the ticket

Throughout the call take notes on the ticket and log outcomes/interactions. Use the VOB Playbook for this step by step guide and resources. 

Reference VOB Advanced Benefits for Exclusions

If documentation is required provide the documentation to the caller via email, send the email directly in the ticket with the attatched file. 

Close the ticket only when the VOB is completed.