Product and procedure coverage check
Before a product is applied, the coverage check answers whether the patient is likely covered for a given Q code with a given CPT code. It combines eligibility, Q code validity on the date of service, CPT pairing with wound size and body site, documentation on file, and each payer's published covered and non-covered product lists.
At a glance
- Availability
- Launching after setupLaunches for a practice after its setup steps. A result is an assessment, not a payment guarantee.
- Part of the cycle
- Authorize: coverage checks, prior authorization, predeterminations
- What it costs
- Included in the full service at 1.5% of insurance collections, meaning payments received from payers. Patient payments are not included.
- Your practice
- Document wound type, measurements and standard-of-care history in the chart
Who does what
Eligibility Hub does
- Check eligibility and whether the Q code is valid on the date of service
- Check the CPT pairing against wound size and body site
- Check the documentation on file: wound type, failed standard of care and measurements
- Compare against each payer's published covered and non-covered product list
- Return the result with its reasons and sources
Your practice does
- Document wound type, measurements and standard-of-care history in the chart
- Make the treatment decision. The check informs it; it does not make it.
What a check returns
Example question: is this patient likely covered for Q4271 with 15271, 15272, 15275 or 15276?
One of four results
- Qualifies
- Needs documentation
- Not covered
- Unknown
With every result
- The reasons behind it
- The sources it used, such as the payer's product list
- What documentation is missing, if any
Limits worth knowing
- No eligibility response can guarantee product-level coverage, and neither can this check. Payers decide.
- Payer product lists change. Each result cites the source it used.
Questions
Why is an eligibility check not enough?
Eligibility confirms the plan is active. It does not say whether a specific product with a specific procedure will be covered. The coverage check closes that gap with payer product lists and documentation rules.
What results can it return?
Qualifies, needs documentation, not covered, or unknown, each with the reasons and the sources it used.
Is it available now?
It is built and launches for each practice after setup: agreements, practice setup, shadow mode and enrollment come first.
Does a qualifies result guarantee payment?
No. Payers decide payment. The check shows what the published rules and your documentation support.
Review the scope before you begin
The full service is 1.5% of insurance collections, meaning payments received from payers. Patient payments are not included. See pricing for how the fee is calculated.
Last updated 2026-10-06