Medicare Eligibility Verification: What to Check

Medicare eligibility verification is the process of confirming that a patient is enrolled in Medicare Part A, Part B, or a Medicare Advantage plan before a visit, and checking what that coverage pays for the service being billed. The front desk runs this check to see the patient's effective dates, deductible status, copay amount, and whether the plan requires a referral or prior authorization. Medicare runs its own system for this, called the HIPAA Eligibility Transaction System (HETS), which providers reach through a clearinghouse, a provider portal, or an electronic health record that is connected to it. A clean Medicare eligibility verification done before the appointment tells the office what the patient owes, whether a secondary payer applies, and whether the planned procedure is covered at all. Skipping this step is one of the most common reasons a claim comes back denied weeks after the visit, once the service already happened and the money is harder to collect.

We run this check every day for practices on Valian, so we hear about it from both sides of the front desk, the team scheduling the visit and the team posting the claim three weeks later. Both sides want the same thing: know before the appointment, not after.

More practices are moving this step off the phone. The ADA Health Policy Institute's 2026 survey found that 43.3% of dentists already use AI for at least one task in the practice, and insurance verification is the second most common planned use, with 32.6% of dentists planning to add it compared to 13.6% that have it live today. Medicare Advantage enrollment keeps growing in general and specialty practices, which is why confirming Part B or Advantage coverage before a crown, a denture reline, or an extraction is turning into a standard front desk task instead of a once-in-a-while check.

This check confirms three things. First, that the patient is active in Medicare on the date of service. Second, which parts apply: Part A (hospital), Part B (medical and many outpatient dental-adjacent services), or a Medicare Advantage plan that replaces both. Third, what that plan pays for the specific procedure code the office plans to bill. The office still picks the codes and decides what to bill; the check only tells you what the plan will pay for that code and what the patient owes.

For Medicare Advantage, the check also needs to confirm the plan name and payer ID, because Advantage plans are run by private insurers (UnitedHealthcare, Humana, Aetna, and others) under contract with Medicare, and each one has its own claim address and rules. A patient can tell you they have Medicare and still have an Advantage plan that behaves like commercial insurance for billing purposes. Our guide on how to verify a patient's Medicare eligibility walks through the fields that trip up a front desk the most.

1. Get the patient's Medicare Beneficiary Identifier (MBI) from their red, white, and blue card. The old Social Security based numbers (HICNs) stopped working years ago.
2. Confirm the patient's legal name and date of birth match what Medicare has on file. A nickname or a maiden name mismatch is a common reason a check comes back blank.
3. Run the check through a clearinghouse, your practice management system if it connects to HETS, a Medicare Administrative Contractor (MAC) portal, or a tool like Valian's insurance verification, where you sign in and check any patient in one click.
4. Read the result for effective dates, Part A and Part B status, deductible met for the year, and whether the plan is Original Medicare or an Advantage plan with a different payer ID.
5. Write down what the patient owes before the visit, not after.

None of this runs on its own. A person at the front desk signs in and runs a check in one click before the visit, reads the result, and decides what to tell the patient at checkout. For a side-by-side on the manual steps versus a connected tool, see real-time eligibility: what it is and how it works.

Providers do not use the 1-800-MEDICARE number; that line is for beneficiaries calling about their own coverage. Providers call their Medicare Administrative Contractor's provider contact center, or use the MAC's interactive voice response (IVR) line, which can read back Part A and Part B status and some deductible information for a specific patient. The number is different depending on which MAC handles your state, so the fastest way to find it is to search your MAC's name plus "provider contact center." Most offices use the phone line as a backup when an electronic check comes back incomplete, not as the first step.

Run the check when you schedule the appointment, so you can tell the patient up front what they will owe. Run it again a few days before the visit if the appointment was booked more than a few weeks out, since Medicare Advantage plans can change network status or drop a patient's enrollment between the booking and the visit date. Check again if it has been more than a couple of months since the patient's last verified visit, especially right after the new year, when many Advantage plans reset deductibles and some patients switch plans during open enrollment.

A complete result tells you: Part A and Part B effective dates, whether the patient has Original Medicare or a named Advantage plan, the Advantage plan's payer ID (needed to file the claim to the right address), deductible met for the year, whether a secondary payer exists, and whether the specific procedure code needs a referral or prior authorization under that plan. If any of those fields come back blank or don't match what the patient told you, that's the moment to call the MAC or the Advantage plan directly, before the visit, not after the claim is denied.

On Valian, the front desk signs in and checks any patient in one click, in seconds, pulling Medicare and other payer coverage from one screen instead of logging into a separate portal for every payer. Nothing runs overnight or on a schedule by itself; a person at the practice decides when to run each check. We keep a running, searchable list of every payer we verify in real time, including Medicare Administrative Contractors, on our payer directory.

Insurance verification on its own starts at $49 a month plus $2.50 or less per check we find, priced by how many checks the office runs each month. The office still enters the appointment in its practice management system; Valian works alongside it rather than writing into it today. Claims and collections work, filing the claim and following up on it, is in development, and we're now taking the first offices into that part of the system.

If your front desk runs Medicare checks by phone or by logging into a separate portal for every plan, you can see how the one-click version works for your schedule by booking a short walkthrough. For the basics on what gets checked on any payer, not just Medicare, our eligibility verification overview covers the fields most offices miss.

How do I call Medicare to verify eligibility?

Providers call their Medicare Administrative Contractor's provider contact center or IVR line, not the 1-800-MEDICARE number, which is for beneficiaries. The MAC that covers your state can read back Part A and Part B status and some deductible details for a specific patient over the phone.

When should a patient's Medicare eligibility be verified?

Check at scheduling, again a few days before the visit if it was booked weeks out, and again after a gap of a couple of months since the last verified appointment. Advantage plans especially can change coverage or network status between January open enrollment updates.

What is an eligibility verification?

An eligibility verification confirms that a patient's coverage is active on the date of service and shows what that plan pays for a specific procedure code, including deductible status and whether a referral is required. It answers "will this be covered and what will the patient owe" before the visit happens, not after the claim is filed.

How do I know if I'll be eligible for Medicare?

Most people become eligible for Medicare at age 65, or earlier with certain disabilities or conditions, and can check their own status and enrollment dates at Medicare.gov. For a specific patient's coverage at your practice, the front desk runs a Medicare eligibility verification rather than relying on what the patient remembers about their own plan.