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RCM & insurance

Verify eligibility and interpret the response

Understand coverage verification, site outcomes, freshness and remaining denial risks.

Current source · source reviewed · 7 min read

Before you begin

1. Open the patient’s revenue episode

Confirm the selected facility and coverage, then use Verify eligibility. On the Eligibility workbench, open the appropriate verification details rather than treating a card as an eligibility answer.

Three explicitly synthetic coverage enrollments remain unverified with unmapped policy, benefit class, network and program fields; their recorded card period does not establish entitlement.
Inspect synthetic member coverage enrollments · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. Three explicitly synthetic coverage enrollments remain unverified with unmapped policy, benefit class, network and program fields; their recorded card period does not establish entitlement.

2. Inspect the decomposed result

Read the response outcome, patient-specific coverage period, benefit information and site statement. Check per-coverage site statements where several coverages were returned.

In the synthetic example, validation processing succeeds and coverage is in force, while network/site, benefit, exclusions, cost sharing and authorization requirements remain unknown. No clearance decision was created. An eligible site result alone cannot establish usable benefit information.

An eligible site response in a local validation fixture remains unusable for benefits when policy/class/network/program mapping is unresolved. The eight site outcomes are distinct desk states.
Read configuration restrictions before estimating · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. An eligible site response in a local validation fixture remains unusable for benefits when policy/class/network/program mapping is unresolved. The eight site outcomes are distinct desk states.
The local validation-only response says processing succeeded and coverage is in force, while five other answer axes stay unknown and no financial clearance decision exists. It is not a genuine insurer answer.
Keep all seven eligibility axes separate · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. The local validation-only response says processing succeeded and coverage is in force, while five other answer axes stay unknown and no financial clearance decision exists. It is not a genuine insurer answer.

3. Check freshness and divergence

Review the configured freshness policy for the service context. If the payer response conflicts with the local policy/class, use the resolution workflow and record evidence rather than overwriting the disagreement.

4. Work unresolved findings

Follow the named queues and blocking gates. An offline verification must retain its provenance and the person who obtained it; it is not interchangeable with a live payer response.

The error example is KB-LOCAL-SIMULATED-OUTAGE, deliberately seeded locally. It is a processing error, not a coverage denial.

KB-LOCAL-SIMULATED-OUTAGE is a deliberately seeded local response error. Unanswered axes remain unknown; the error is not converted into a coverage denial.
Identify a simulated eligibility processing error · 2026-10-18. Current audited MANSOQ application in an isolated local synthetic training environment. KB-LOCAL-SIMULATED-OUTAGE is a deliberately seeded local response error. Unanswered axes remain unknown; the error is not converted into a coverage denial.

Eligibility is not a payment guarantee

The API explicitly returns guarantees_payment and residual_denial_risks. Authorization, clinical justification, coding and other claim conditions can remain unresolved even after positive eligibility.

Discovery ladder

Configured discovery channels have an ordered hierarchy. A missing rung is surfaced rather than silently promoting a weaker source; inspect the configured ladder when discovery results disagree.

What the current screenshots demonstrate

These are current captures from an isolated Polyclinic training environment, using explicitly fictional insurance, response, authorization, remittance and policy fixtures. They demonstrate the displayed controls and scoped observations only. They do not establish live payer connectivity, a genuine insurer approval, regulatory qualification, production tax filing, a complete role/facility matrix or a cleared financial estimate.

Troubleshooting

The button is unavailable

Ensure the episode has coverage and your role can perform the action. If setup is incomplete, have the coverage and integration owners correct the named prerequisite.

Source evidence

References are pinned to the private MANSOQ source repository. Repository access is required to open these links.