Solution · Eligibility & Benefits
Insurance eligibility verification software that catches coverage problems before the visit.
Simz runs real-time eligibility (EDI 270/271) on every scheduled visit days ahead, parsing full benefit detail, re-checking when coverage changes, and surfacing only the real problems to your staff. The front desk greets patients instead of interrogating payers.
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The cost of this bottleneck
Your staff's first job every morning: payer hold music
Verification happens by portal and phone, payer by payer, morning by morning, and it still misses things, because “active coverage” isn't the same as “this service is covered, at this benefit level, with this much left”.
…and the misses become denials, surprise balances, and write-offs downstream.
Each payer, its own portal, every morning, the same lookups, forever.
Visit limits, frequencies, waiting periods, and remaining maximums decide payment, and manual checks skip them.
Verified at booking, changed by the visit, and nobody re-checked.
Coverage problems discovered at check-in become awkward conversations and unpaid bills.
Eligibility failures are among the most common, and most preventable, denial causes.
BEFORE / AFTER
How it works today vs. with Simz
The morning of, if staffing allows
Portals and phone calls, payer by payer
Active or inactive
Rarely re-checked
Do every check
HOW IT WORKS
The automation, step by step
Batch verification days ahead
Every scheduled visit checked automatically on a rolling window, no morning marathon required.
Full benefit parsing
The 271 response parsed into usable detail: plan status, copays, deductibles, visit limits, frequencies, waiting periods, and remaining maximums, filed to the record.
Exception worklists
Clean verifications file silently; problems, inactive coverage, exhausted benefits, plan changes, surface to staff with the reason attached.
Re-checks on change
Coverage re-verified automatically before the visit and when payer data changes, booking-day verification doesn't go stale.
Feeding everything downstream
Verified benefits drive workflow routing, patient estimates, the prior-auth engine, and in-call verification on the phone agent, one engine, every workflow.
Rolling batch checks
Every scheduled visit verified days ahead, automatically.
Full benefit breakdowns
Limits, frequencies, waiting periods, and remaining maximums, not just active/inactive.
Exception-only worklists
Staff see the problems, not the paperwork.
Automatic re-verification
Coverage re-checked before the visit and on changes.
In-call verification
The same engine verifies coverage live while a caller is on the phone.
Denial prevention
Eligibility failures caught before service, the cheapest denial is the one that never happens.
The multiplier effect: This is the engine under everything else, accurate eligibility powers the auth rules, prevents the denials, enables in-call phone verification, and makes patient estimates trustworthy.
Where it bites hardest
See this automation in your specialty
Why we're confident
This engine is already running in production
The platform behind this solution is live today with a multi-site radiology group in Southern California, a phased engagement covering AI intake, real-time eligibility, authorization tracking, a 24/7 phone agent, and analytics, on one MSA, one BAA, one HIPAA framework.
Powered by Simz Conversational, Simz Shift, and Simz Chron, with custom development for everything else.
- BAA executed before any PHI moves
- HIPAA-eligible infrastructure end to end
- Human review on every uncertain AI decision
- Role-based access with full audit logging
- Accuracy benchmarked on your documents, and locked as acceptance criteria
FAQ
Eligibility & Benefits Verification, answered
Kill this bottleneck first.
Thirty minutes with your operations lead. We map how eligibility & benefits verification works in your practice today, quantify what it's costing you, and hand you an automation roadmap, whether or not you build it with us.