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The Anatomy of a Patient Insurance ID Card and What It Means

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The Anatomy of a Patient Insurance ID Card and What It Means

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Insurance ID card

Your front desk staff members have an incredibly important job, and one critical responsibility is to get patient insurance ID card information when patients make an appointment, and then scan those cards when patients come in for their visits.

Just as important as it is to gather information from a patient insurance ID card, it’s also essential to know what the details on those cards mean. Check out a few tips below that can help you decipher this information.

Member Name

This field may sound straightforward, but it can actually lead to confusion. The Member Name typically matches that of the patient, but some insurers only list the name of the person who holds the policy. Particularly when pediatric patients are involved, the Member Name may be the name of the patient’s parent or guardian and not their own name.

In most cases, if the patient is not the policyholder, both names may be listed on the card, with the policyholder listed in one field and the covered dependent (your patient) listed in another field on the card.

Member ID

Some insurance cards will just say “ID,” some will say “Member ID” and some may use other terms, like “Subscriber ID” or “Policy Number.” Either way, this is a critical piece of information that identifies the patient to the insurance company. You’ll need the member ID to verify benefits, submit claims and inquire about denials or late reimbursement.

Sometimes the patient and their dependents will have similar policy numbers, and sometimes not. For instance, if the policyholder’s Member ID number is 1234-0, their spouse might have the policy number 1234-1. It’s important to gather any numbers both before and after the hyphen to ensure your patient name matches their Member ID number. If it doesn’t, you may face denials.

Group Number

Also called “Group,” “Group ID” or “Group Plan,” this reveals the source of the health plan, such as the patient’s employer program. Because each employer may create a different benefits plan, the Group Number tells the insurer which specific benefits are available to the patient.

If you see a Group ID on a patient’s insurance ID card, make sure to record it. However, not every policy has a Group ID. For instance, many policies that are acquired through the Affordable Care Act marketplace do not have Group Numbers.

Contact Information 

It’s very important to take note of the contact information on the card, since many payers will have different phone numbers and claims addresses depending on where the patient lives or which employer covers them. This information is usually on the back of the insurance card, so make sure you copy the front and back of the card at every visit to collect the insurer’s name, phone number, address, website and fax number (if applicable).

Coverage Amounts and Percentages

Not all insurance ID cards have coverage amounts and percentages on them, but some will denote the amount the patient is responsible for directly on the card in terms of their copay or coinsurance. This may be listed in a variety of ways. For instance, the card may say “PCP: $20” and “SPC: $50,” which means they have a $20 copay for seeing their primary care physician and a $50 copay for seeing a specialist.

In other cases, the card may simply note a percentage, such as “In-network: 15%, Out-of-network: 30%.” Keep in mind that there may be other nuances to the patient’s coverage responsibilities beyond these numbers. For instance, the patient may have to meet a $500 deductible before the coinsurance kicks in. That’s why it’s essential to verify all benefits with the payer using the Member ID and Group Number ahead of time.

Your front desk is critical to smooth operations at your practice. Get more actionable tips from expert Tracy Bird, FACMPE, CPC, CPMA, CEMC, CPC-I. During her online training, Front Desk Fundamentals That Guarantee Success, she’ll share must-have strategies to enhance your front desk success rate. Register today!

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