The signature mechanic
Three round-trips before the visit. One prior-auth clock running.
A 270 goes out and a 271 comes back at booking, again at T-24h, and once more at check-in — each pass refreshing the parsed benefits card. When a benefit signals “requires PA,” a 278 (or Da Vinci PAS bundle) opens a tracked request on the payer's 72-hour expedited / 7-day standard clock.
Five org-scoped entities carry it — InsurancePlan, Coverage, EligibilityCheck (raw 270/271 retained for compliance), BenefitDetail (one row per EB service-category line), and PriorAuth. Coverage maps to FHIR R4 Coverage on the wire; multi-coverage is ranked 1/2/3 for coordination-of-benefits.
The problem
Coverage surprises become denials. Denials become write-offs.
Practices learn that insurance is inactive, the deductible reset, or a procedure needs prior auth on the day of service — sometimes with the patient already in the exam room. Front desk staff re-key insurance cards into clearinghouse portals; billers rework denials that could have been blocked at scheduling; patients get surprise bills weeks later.
Three checks, zero surprises
A 270 fires automatically when the slot is booked — the booking screen shows active/inactive status and copay before the appointment is confirmed. A T-24h batch job re-verifies tomorrow's entire panel, surfacing mid-month coverage flips on the front-desk dashboard. At check-in, a final verification (or a cached response under 4 hours old) catches same-day changes.
Prior auth without the fax machine
When the parsed benefit signals “requires PA,” an electronic prior-auth request is built — X12 278 or a FHIR Da Vinci PAS bundle per CMS-0057-F — and tracked to a final decision on the payer's 72-hour expedited / 7-day standard clock. Status pings the ordering clinician's inbasket. Fax exists only as a fallback bridge for payers that haven't caught up.
Key capabilities
The benefits picture — canonical, structured, and present at every gate.
Real-time 270/271 at booking
Fires automatically from Scheduling when a slot is booked; the result decorates the appointment. Sub-3-second round trips when the payer is healthy.
T-24h batch refresh
A scheduled job re-verifies every next-day appointment, so the practice learns about coverage changes before the patient is at the desk.
Insurance card OCR
Photograph the front and back of the card; payer ID, member ID, and group number extract automatically and a 270 fires to validate before the patient leaves the lobby.
Parsed benefit normalization
The dense EB segments of a 271 become a stable, payer-agnostic benefit summary: copay, deductible state, OOP max, in-network status, referral and PA requirements.
Electronic prior auth (ePA)
X12 278 and FHIR Da Vinci PAS submission with closed-loop decision tracking — mandatory plumbing for CMS-0057-F-impacted payers, native here.
Pre-service cost estimates
Planned CPT codes priced against the parsed benefit — copay vs. deductible vs. coinsurance — shown to the patient at booking. Honest estimates, fewer billing disputes.
Multi-coverage & COB
Primary, secondary, and tertiary coverage ranked with coordination-of-benefits math for accurate estimates and claim routing.
Workflow gating
Visit types that require active coverage are blocked from confirmation when the 270 returns inactive — with explicit override paths for self-pay and sliding-scale patients.
Clearinghouse failover
Primary and backup clearinghouse orchestration with automatic failover when the primary degrades. Payer outages don't become your outages.
Workflow
From booking to check-in, verified three times.
Patient books Thursday 2:14 pm
The 270 fires on confirmation. Active coverage, $30 copay, deductible state — on the booking screen before the call ends.
Wednesday 2:14 pm: batch re-check
The T-24h job re-verifies the whole Thursday panel. One patient's plan terminated at month end — the front desk sees the flag today, not tomorrow.
Front desk calls before the visit
The patient brings their new card; OCR captures it, the 270 validates the new coverage, and the appointment keeps its slot.
Check-in: final verification
A cached-or-fresh check confirms coverage; the copay is collected; the visit starts clean.
The claim never bounces
Eligibility-related front-end denials stay under half a percent — the failure mode was removed at booking, not appealed afterwards.
Who benefits
Card OCR plus auto-fired 270 replaces a six-tab manual workflow with one screen. Wins the most.
Coverage problems move from post-claim rework to pre-visit prevention. Denial root causes dry up at the source.
PA requirements appear inline with order entry; ePA submission is one click from the order, not a fax to the front desk.
An honest cost estimate at booking — and no surprise denial letter weeks later.
Performance targets
The numbers this module is built to hit.
| Metric | Target |
|---|---|
| 270/271 round-trip latency (payer healthy) | ≤ 3 seconds p95 |
| Eligibility check coverage at booking | ≥ 99% of confirmed appointments |
| Parsed-benefit accuracy vs. payer EOB | ≥ 98% |
| T-24h re-verification of next-day appointments | ≥ 95% |
| ePA submission-to-decision median | ≤ 24 hours |
| Eligibility-related front-end denials | ≤ 0.5% of submitted claims |
| Cost-estimate accuracy vs. final patient responsibility | within ±15% on ≥ 85% of estimates |
Standards & the 2027 mandate
Built for the prior-auth rules that land next year.
CMS-0057-F requires impacted Medicare Advantage, Medicaid, CHIP, and FFE-QHP payers to stand up prior-auth and Provider Access APIs by January 2027. rev.health flags each plan's IsCMS0057FImpacted, SupportsX12278, and SupportsDaVinciPAS capabilities and routes to the best available channel — fax remains only as a fallback bridge.
Connected modules
Eligibility gates the whole journey.
Scheduling
Every confirmed slot triggers verification; gating signals flow back to the booking screen.
Module 02 →Revenue Cycle
Coverage data feeds claim routing; eligibility failures are denial root causes — prevented here.
Module 07 →Patient Portal
Cost estimates surface to the patient at booking and before the visit.
Module 08 →Stop discovering coverage problems in the exam room.
Verified at booking, T-24h, and check-in — with prior auth tracked to closure.
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