Pre-Billing Eligibility Edits

Avoid lost revenue by catching potential
eligibility-related denials before submission to payers

Each year, billions of dollars in denials can be attributed to preventable eligibility denials. Eligibility-related denials are one of the top five most common types of denials—often resulting in a hard denial or one where you will not likely be paid.

SSI PBE acts as a safety net, allowing providers a final eligibility check to catch potential denials on the back end before submission to payers. Available as an add-on to SSI’s robust Edits library, SSI PBE is easily integrated into your existing billing workflow.

Solution Highlights

Complements your existing front-end eligibility processes

An added safety net for preventing rejections, denials, and reimbursement delays

Easily integrated into your existing billing workflow

Keeps your patients and payers happy by submitting accurate and complete claims the first time


The SSI team of claims edit analysts and product management members review adjustment reason codes to determine which codes represent the bulk of the revenue at risk. The team then creates PBE warning edits to stop claims and prevent eligibility-related denials.

During the SSI claims translation process, demographic claim data is used to create 270 eligibility requests. When 271 eligibility responses are received from payers, coverage and benefit discrepancies are identified as edits on claims. Billers can then review full 271 responses and update the host system accordingly. Once patient accounts have been updated, claims are re-dropped and re-verified. If no further benefit discrepancies are identified, claims are validated and billed in the next bill job.


The Medicaid continuous coverage requirement put in place during the COVID-19 pandemic to ensure that individuals remain eligible for Medicaid coverage ends April 1, 2023. This means that states will begin the process of “unwinding” the coverage by reviewing the eligibility of every person enrolled in Medicaid. Estimates suggest that over 15 million beneficiaries could be affected, leading to an increase in uninsured patients seeking care at hospitals and financial challenges for providers that do not have a robust system in place for verifying eligibility. To stay on track during the unwinding process, we recommend implementing best practices such as regularly running insurance eligibility checks throughout the patient encounter and utilizing solutions like SSI PBE as a final safety net for checking eligibility. By being proactive, you can minimize the potential negative impact of the unwinding process on your patients and your bottom line. Read our recent blog post for more information on Medicaid unwinding.