The payer question belongs before the claim.
Coverage verification, benefit requirements, and authorization are different checks. Map the payer and the handoff before a missing answer becomes a billing exception.
Lucy Mfinanga · Revenue operations lead
Prepare the first conversation
Show us where the handoff breaks.
Answer what you know; every question is optional. Your agency-level choices prepare an editable medical billing service brief. This is not a coverage decision, recovery estimate, quote, or patient intake. Only these fixed choices travel to Contact; nothing is sent until you review and submit it there.
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The workflow
How the intake question is separated
- 01Identify the payerSeparate Medicare fee-for-service, Medicare Advantage, Medicaid, and other contracts before applying an authorization or review rule. The agency keeps the clinical eligibility decision.
- 02Name each checkCoverage status, home-health benefit requirements, plan authorization, and any applicable pre-claim review are distinct questions. The written scope names who obtains and records each answer.
- 03Track exceptionsAn unknown, expired, or conflicting payer response needs an owner and a next check. It should not silently become a clean-to-bill signal.
- 04Hand off to billingThe billing desk receives the dated status and unresolved items through the agency-approved system. No patient record belongs in this website inquiry.
Before the quote
Find the missing answer before it reaches a claim.
A coverage response, a clinical certification, and a payer authorization answer are not interchangeable. A useful intake review starts with payer mix and handoff ownership, using agency-level counts rather than patient records.
- 01
Which payer path?
Separate Original Medicare from Medicare Advantage, Medicaid, and other plans. Identify the agency's states, payer contracts, and where each payer publishes its current requirements.
- 02
Which question is open?
Record coverage status separately from home-health benefit and clinical eligibility, plan authorization, referral requirements, and any applicable Medicare review-choice process. A positive response to one is not approval of the others.
- 03
Who owns the exception?
Name who requests missing information, follows a pending payer answer, checks its validity period, and tells scheduling and billing what remains unresolved. Do not turn silence into an approved status.
- 04
What reaches billing?
Agree on the dated status, source, relevant service window, open exceptions, and handoff owner in the agency's approved system. The public inquiry only needs payer mix and agency-level volumes.
What gets scoped
A proposed service scope identifies payer mix, referral volume, current intake tools, responsibility for each check, escalation, and the secure record handoff. It does not promise payer approval, coverage, clinical eligibility, or payment. Do not put patient information in a public form or help chat; a business associate agreement and approved channel come before record access.
Before you choose
Questions worth settling before you book.
- Is an eligibility response the same as authorization?
- No. An eligibility transaction reports available coverage information. Authorization and medical-review requirements depend on the payer, plan, service, and setting. The agency must verify the applicable rule and keep each answer separate.
- Does every Original Medicare home-health episode need prior authorization?
- Do not assume one national authorization rule. CMS's Home Health Review Choice Demonstration applies to specified agencies and states and offers pre-claim or postpayment review paths; other payer plans have their own requirements. Confirm the current path for the agency and payer.
- Who determines whether a patient clinically qualifies?
- The agency and authorized clinician retain clinical assessment, certification, and plan-of-care responsibilities. An administrative coverage check does not replace those judgments.
- Can we send a referral or payer screenshot through the website?
- No. Use this form only for agency-level needs. Do not include names, dates of birth, member identifiers, authorization numbers, or records. Any patient-data workflow requires an appropriate agreement and approved secure channel first.
Service here · product under NEXUS
NEXUS product availability is separate. This page discusses medical billing service scope, not a software license.
See the NEXUS product pathWhat you get
- A payer-by-payer scope distinguishes Medicare fee-for-service, Medicare Advantage, Medicaid, and other contracts rather than assuming one rule fits all.
- The intake handoff names who checks coverage, who confirms any plan authorization or applicable review path, and who follows an unresolved answer.
- Clinical eligibility and certification remain with the agency and the authorized practitioner; a coverage response is not a clinical or payment guarantee.
- The agreed workflow carries the dated payer response and open exceptions to the billing desk without putting patient details in a website form.
How we quote
- Scope
- Quoted after review
For
For home-health owners, intake leads, and billing teams who need to know which coverage, clinical, and payer-review questions have an owner before a visit becomes a claim.
Primary sources
Coverage and review have separate rules.
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