From Eligibility Verification to Payment Posting — The Complete RCM Workflow for San Antonio Practices
Revenue cycle management is often discussed as a single function. In practice, it is a sequence of distinct, interdependent steps — each one affecting the accuracy and speed of every step that follows. A failure at step two doesn't just affect step two. It creates errors that compound through steps three, four, and five before anyone sees a denial or a delayed payment.
For San Antonio healthcare providers, understanding what happens at each stage of the revenue cycle — and where the highest-risk failure points are in Bexar County's payer environment — is the foundation of effective billing oversight.
This guide walks through every stage of the San Antonio RCM workflow, from the moment a patient schedules an appointment to the moment the final payment is posted and the account is closed.
Stage 1 — Patient Scheduling and Registration
The revenue cycle begins at scheduling — not at billing. Every piece of information collected at the front desk either supports or undermines the claim that will eventually be submitted for that encounter.
What must be captured accurately at registration:
• Patient legal name — exactly as it appears on the insurance card and in the payer's system
• Date of birth — used by payers for member identification and eligibility verification
• Insurance ID number and group number — copied directly from the insurance card, not entered from memory
• Payer name and plan type — critical for San Antonio practices that must distinguish between TRICARE Prime, TRICARE Select, TRICARE for Life, and TRICARE Reserve Select at the point of registration
• Secondary insurance information — including Medicare as primary for TRICARE for Life patients and STAR+PLUS dual-eligible Medicaid patients
• Referring provider information — required for TRICARE Prime referrals and certain commercial payer claims
Registration errors are the upstream source of many downstream denials. A transposed insurance ID number at scheduling becomes an eligibility denial at the payer level. A missing secondary payer record becomes a coordination-of-benefits error at payment posting.
Stage 2 — Insurance Eligibility Verification
Eligibility verification is the most consistently underperformed step in the revenue cycle for San Antonio practices. Many practices verify eligibility at scheduling — once — and assume it remains accurate through the appointment date. It does not.
What eligibility verification must confirm:
• Active coverage on the date of service — not just on the date of scheduling
• Deductible status — how much of the patient's annual deductible has been met
• Copay and coinsurance amounts — for accurate patient collection at the point of service
• Covered benefits — whether the specific service being scheduled is a covered benefit under the patient's plan
• Network status — whether the provider is in-network under the patient's specific plan, not just the payer generally
• Authorization requirements — whether the scheduled service requires prior authorization before it can be rendered
• TRICARE program type — which specific TRICARE plan the patient holds, confirmed through Humana Military's eligibility portal
• TMHP managed care plan — which specific managed care organization holds the patient's current Medicaid enrollment
When eligibility must be verified:
Eligibility must be verified at scheduling and again within 24 to 48 hours before the appointment date. For Medicaid patients, re-verification is critical because TMHP managed care enrollment changes monthly. A patient who was enrolled with one managed care plan at scheduling may have switched plans by the appointment date.
Stage 3 — Prior Authorization Management
Prior authorization is the step where the most expensive, most avoidable denials originate. A service rendered without a valid prior authorization on file cannot be billed retroactively in most cases — the revenue is simply lost.
Services that commonly require prior authorization in San Antonio:
• Specialty referrals under TRICARE Prime — all specialty care requires a PCM referral and, for many procedures, an additional prior authorization
• Advanced imaging — MRI, CT, PET scans require prior authorization under most San Antonio commercial payers and TRICARE
• Surgical procedures — elective and semi-elective surgical procedures require PA under TRICARE, TMHP managed care, and most commercial plans
• Behavioral health services — session limits, telehealth authorizations, and intensive outpatient program approvals require advance authorization under virtually every San Antonio payer
• Home health and DME — durable medical equipment and home health services require prior authorization under TMHP and Medicare Advantage plans
The prior authorization workflow:
Step 1 — Identify whether the scheduled service requires authorization for the patient's specific plan
Step 2 — Submit the PA request with supporting clinical documentation before the appointment date
Step 3 — Track the authorization status and confirm approval before the patient arrives
Step 4 — Document the authorization number and attach it to the claim at submission
Step 5 — Verify that the authorization covers the specific procedure codes that will be billed — not just a general service category
Stage 4 — Medical Coding
Medical coding translates clinical documentation into the standardized codes that payers use to process claims. Coding accuracy determines both the revenue generated by each claim and the compliance risk associated with it.
Code sets used in San Antonio RCM:
• CPT codes — all professional services, office visits, procedures, and tests
• ICD-10-CM — diagnosis coding for outpatient and professional services to the highest level of specificity supported by documentation
• ICD-10-PCS — inpatient procedure coding for hospital-based providers
• HCPCS Level II — supplies, durable medical equipment, drugs, and non-CPT services
• E/M codes — evaluation and management coding under the 2021 AMA framework, using medical decision-making or total provider time
Common coding errors that generate denials in San Antonio:
• ICD-10-CM codes assigned without full specificity — using a non-specific code when a more specific code is supported by documentation
• Missing or incorrect modifiers on multi-procedure encounters — particularly BCBS Texas bundling edits that require modifier 59 or X-modifiers to establish separate and distinct procedures
• NCCI edit violations — procedure code pairs that trigger automatic bundling without correct modifier application
• E/M level mismatch — billing a higher E/M level than the documented medical decision-making supports
Stage 5 — Claim Scrubbing and Submission
Before any claim is submitted to a payer, it passes through a claim scrubbing process — an automated and manual review that catches errors before they generate denials.
What claim scrubbing reviews:
• NCCI edit compliance — procedure code pairs that trigger automatic bundling
• LCD/NCD policy alignment — Local Coverage Determinations and National Coverage Determinations for Medicare-billed services
• Modifier validation — confirming that all modifiers are appropriate, necessary, and payer-accepted
• Diagnosis code linkage — confirming that every procedure code is linked to a supporting diagnosis code
• Payer-specific formatting — confirming that claim format meets the specific requirements of each payer
Clean claims submit electronically within 24 to 72 hours of the patient encounter. Delayed submission increases A/R days and — for payers with short timely filing windows — increases the risk of timely filing denials.
Stage 6 — Denial Management and Appeals
Denied claims require immediate, systematic response. Every denial that is not worked within the payer's appeal window becomes unrecoverable revenue.
The denial management workflow:
Step 1 — Receive the denial and log it with the denial reason code, payer, and original submission date
Step 2 — Perform root-cause analysis — determine whether the denial is a coding error, authorization miss, eligibility issue, or timely filing problem
Step 3 — Correct the error and prepare the appeal with supporting documentation specific to the denial reason
Step 4 — Submit the appeal within the payer's timely filing window — typically 30 to 180 days from the denial date depending on the payer
Step 5 — Track the appeal status and escalate to payer provider relations if no response is received within the payer's stated turnaround time
Step 6 — Document the outcome and analyze whether the denial pattern indicates a systemic process failure that requires a front-end correction
Stage 7 — Payment Posting and Patient Billing
Payment posting is the step where insurance payments are matched to the corresponding claims, contractual adjustments are applied, and patient responsibility balances are identified.
What accurate payment posting requires:
• ERA (Electronic Remittance Advice) and EOB (Explanation of Benefits) matched to correct claims
• Contractual adjustments posted at the correct contracted rate — not estimated
• Underpayments flagged for audit when the payment received is less than the contracted rate
• Patient balance identified and billed promptly after insurance payment is posted
• Secondary payer billed immediately after primary payer payment is posted — critical for TRICARE for Life and STAR+PLUS dual-eligible patients
Stage 8 — Reporting and Continuous Improvement
Monthly financial reporting closes the revenue cycle loop — turning billing data into operational intelligence.
What monthly RCM reports should cover:
• Net collections by payer and by provider
• Denial rate by payer and by denial reason code
• First-pass claim acceptance rate
• A/R aging distribution — 0–30, 31–60, 61–90, 91–120, and 120-plus day buckets
• Write-off analysis by category
• Coder productivity and coding accuracy metrics
• Prior authorization approval and denial rates by payer
For San Antonio practices, payer-specific reporting is essential — overall metrics can mask poor performance on TRICARE or TMHP claims that is offset by strong commercial payer results.
Frequently Asked Questions
Why does eligibility verification need to happen twice — at scheduling and before the appointment?
Insurance coverage changes between scheduling and the appointment date — particularly for Medicaid patients whose TMHP managed care enrollment changes monthly. A single eligibility check at scheduling does not guarantee accurate payer information on the date of service.
What happens if a prior authorization is not obtained before the service?
Most payers — including TRICARE and TMHP managed care plans — do not allow retroactive authorization. Services rendered without a valid prior authorization on file are denied, and the denial is typically not reversible through the standard appeal process. The revenue is lost.
How quickly should denied claims be appealed?
Every denied claim should receive a documented response within 24 to 48 hours of receipt. Payer appeal windows range from 30 to 180 days depending on the payer — but the earlier an appeal is submitted with complete documentation, the higher the probability of successful recovery.
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