Better Systems, Better Care

Accurate eligibility verification is foundational to ensuring trust, cost transparency, and timely access to care. Below, we identify key pain points commonly encountered in current eligibility workflows and detail the targeted solutions Nirvana has engineered to address these gaps. Check out our blog for regular updates on how we're solving eligibility challenges and making sense of healthcare systems.

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Nirvana Fixes Common Eligibility Verification Problems

🧾 Patient Info & Policy Basics

Incorrect patient data = denied claims
Nirvana auto-corrects name, DOB, and ID mismatches before information is submitted and claim is denied.
Wrong subscriber = rejected claims
Nirvana identifies the correct patient–subscriber relationship enabling clean claims submission.

✅ Coverage Validation

Unknown coverage status = lost revenue
Nirvana instantly confirms active or inactive status –no guesswork required.
Expired plans may still look active
Nirvana proactively flags end dates to avoid billing expired policies.
Multiple policies = coordination of benefits chaos
Nirvana detects and prioritizes policies in order to prevent rejections.

📘 Plan & Insurance Type Clarity

Plan types impact billing rules
Nirvana distinguishes Medicare, Medicaid, commercial, and marketplace plans.
HMO vs PPO vs EPO? It matters.
Nirvana shows insurance type to guide referrals and authorizations.

💰 Financial Responsibility & Compliance

Patients need cost clarity prior to receiving care
Nirvana shows accurate copay, deductible, and coinsurance up front, enabling pre-session collections.
Telehealth billing is different than in office billing
Nirvana separates in-person vs. virtual coverage and costs.
Qualified Medicare Beneficiary status = no balance billing
Nirvana flags QMB so you're always in compliance.

🧠 Behavioral Health Specifics

Unknown carveouts cause denials & delay payments
Nirvana flags mental health carveouts so providers bill the right payer the first time.