Patient/Beneficiary Validation Function: Tools and Specifications

Executive Summary

Healthcare providers that are part of a Health Information Exchange (HIE) must assess whether the patient is enrolled in a health plan, and covered for the treatments or services they are seeking. The role of a patient/beneficiary validation function in HIE is to display the patient’s eligibility and benefits with a medical plan/payer. Verification via HIE aims to automate the process between the care provider’s organization and the payer. 

This article provides a list of tools that serve as samples for either the format or content of the specifications documentation for a Patient/Beneficiary Validation Function.

Companion Article

A Guide to Planning a Health Information Exchange (HIE)


The Function

Before providing care, a provider verifies that the patient is a beneficiary and to what extent they are covered for the treatment or services being sought. Please see use case #11 of PAeHCO's documented use cases.

Examples of specifications for one application of a patient/beneficiary validation function: 

The Ontario Ministry of Health and Long-Term Care's Health Card Validation (HCV) service determine's patient eligibility for publicly administered healthcare services and validity of the Ontario health card. The following document outlines the minimum requirements of the HCV system: 

Examples of data needed to verify eligibility:

The Michigan Department of Health and Human Services has put together a Medicaid Provider Manual which addresses all health insurance programs administered. Section 3 describes the beneficiary information that is used to verify beneficiary eligibility.


Specifications and Tools:

A complete list of tools for building out the specification documentation of a component of an HIE including business requirements, interoperability standards, workflow documentation, etc. can be seen in the article based off of a Master Patient Index.