Verification processing

To support Texas prompt pay legislation, Ascension Personalized Care has a verification of benefits process. Clinicians have the right to request a verification of benefits guaranteeing that a particular service will be paid by the insurance carrier for applicable Ascension Personalized Care members.

Verification definition

The Texas Department of Insurance (TDI) defines verification as “a guarantee by an HMO or preferred provider carrier that the HMO or preferred provider carrier will pay for proposed medical care or health care services if the services are rendered within the required timeframe to the patient for whom the services are proposed.”

TDI Required Data Elements

Before submitting a request for verification, please be prepared to provide all of the following TDI required data elements at the time of your request.

  • Patient name
  • Patient identification number (exactly as shown on the current ID card)
  • Patient's date of birth
  • Name of enrollee or subscriber
  • Patient relationship to enrollee or subscriber
  • Presumptive diagnosis, if known, otherwise presenting symptoms
  • Description of proposed procedure(s) or procedure code(s)
  • Place of service code where services will be provided and if the place of service is other than the clinician’s office or clinician’s location, name of hospital or facility where proposed service will be provided
  • Proposed date of service
  • Group number
  • Name of the clinician providing the proposed services(s)
  • Clinician's federal tax identification number
  • If known to the clinician, name and contact information of any other carrier including:
  • Other carrier's name
  • Address
  • Telephone number
  • Name of enrollee
  • Plan or Identification number
  • Group Number (if applicable)
  • Group Name (if applicable)

Submission of verification

To request a verification submit the clinician verification form. Please complete this form in its entirety. Any omitted fields (other than the optional information) will result in this request being incomplete and unable to be processed. Upon completion of processing, clinicians will receive a fax notice of the verification.

Declination notice

Verification is voluntary and may not be available to all members and/or clinicians. Some examples of reasons for declination may include, but are not limited to:

  • No coverage or change in eligibility, including individuals not eligible, not yet effective or canceled
  • Premium payment timeframes that prevent verifying eligibility for a 30-day period
  • Policy deductible, specific benefit limitations or annual benefit maximum
  • Benefit exclusions
  • Pre-existing condition limitations
  • Ascension Personalized Care is the secondary carrier

A declination notice simply means that a guarantee of benefit cannot be issued in advance, not a determination that a claim will not be paid. Please be advised that routine eligibility and benefit information may be obtained when verification is not applicable, or a declination has been issued.