Verify the benefit, not just the plan.
An active plan says nothing about the treatment you are about to deliver. Foresight investigates coverage, cost share, authorization, and network for the exact service, provider, and site.
| Fact | Answer | Status |
|---|---|---|
| Coverage | Active · behavioral health carved out to Optum271 · Claim.MD | Confirmed |
| Prior auth · 90868 | On file · 22 of 36 sessions remainingRecords on file | Confirmed |
| Network | In network · rendering provider · Clinic ACredentialing roster | Confirmed |
| Coinsurance · 90868 | 20% after deductible271 · procedure level | Confirmed |
| Visit limit | 36 per plan year271 · service-type level | Reported |
| Other coverage | NonePayer call · ref 4471 | Confirmed |
Ask every source that can answer.
A 271 answers a few questions. Foresight asks everything that can answer for this member and this service.
Eligibility sources like Stedi, pVerify, Claim.MD, and Availity, and payer connections like Optum for UnitedHealthcare plans.
Records on file: an authorization already granted, sessions used and remaining, prior findings for the same patient.
Insurance discovery for coverage the patient did not report, and a payer call for anything still open.
Every fact keeps its source.
Answers land in an append-only ledger with source, scope, and time. Fixed precedence decides which source can close a fact: a payer's answer outranks a plan document, and two plans are never merged. What remains open stays visible, with the reason.
| Source | Answer | Status |
|---|---|---|
| Plan document | 36 per plan yearobserved Sep 2 | Reported |
| 271 · service-type level | 36 per plan yearobserved Sep 18 | Reported |
| Payer call · ref 4471 | 30 per plan yearobserved Sep 19 | Confirmed |
The payer’s answer closes the fact. Earlier rows stay on record; nothing is edited.
Procedure-level when the payer gives it.
If the payer answers for the CPT code, that answer is used. Otherwise the service-type answer is used and labeled as such. A plan-level response is never proof for the service.
Cost share computed the way the plan adjudicates.
Copay or deductible first, in plan order. Deductible only when it applies. Coinsurance on the remainder, capped at the out-of-pocket left. Every estimate names its basis. An unknown stays unknown, not zero.
The call asks only what is still open.
Foresight knows the number and department for the question, works the IVR, holds, and identifies the practice. It asks only what no other source confirmed, branches on the answers, and pushes back when an answer conflicts with the plan documents. Answers and the reference number return to the case as evidence.
- 01Other coverage on file? → None
- 02Visit limit for 90868? → 30, not the 36 in the plan document. Challenged; 30 confirmed.
- 02a · branchSessions used this plan year? → 14
- CloseReference 4471 · representative recorded
Find the right payer, in the right order.
Detect a behavioral-health carve-out and ask the administrator that owns it. Resolve primary, secondary, and tertiary coverage. After primary adjudication, the secondary claim generates itself.
Re-verify when coverage changes.
Every 271 is compared with coverage on file. A new payer, member ID, plan, or payer order triggers a recheck of eligibility, prior auth, and cost before the visit. Evidence expires on schedule, so a stale fact is never shown as current.