← Insurance Verification, AnsweredWhat information is needed to produce a patient estimate?
Five things: the patient's identifiers and member ID; the CPT code or codes for the planned service; the place of service; the rendering provider's NPI; and the provider's fee schedule or contracted rate with that payer. The first three inputs are what distinguish benefits verification from an eligibility check, and the last is what turns benefits into a dollar figure.
The CPT code determines which benefit category applies and whether prior authorization is needed. The place of service changes the tier, copay and sometimes coverage itself. The NPI determines network status for this specific provider, which is not always the same as the practice's. The fee schedule is the number the patient's coinsurance and deductible are applied to. Tools that never ask for these cannot be producing a real estimate.
Last reviewed October 8, 2026
