Insurance Verification & Coordination of Benefits

Before you can submit visits and get paid, Loula verifies your client's insurance. This confirms their plan is active, covers doula care, and identifies which coverage to bill.

Verification happens at a few points:

You'll see your client's current status on their profile. The sections below walk through what each status means and what to do.

If you're part of a group: all shared doulas and group admins get these emails too, except onboarding-only members (doulas who are in a group but do not have portal access). This is noted again below wherever it applies.

Verification works best as a two-way effort. Loula runs the process, but we can only verify what you share with us!

A few things worth keeping in mind:

Most Medi-Cal clients are enrolled in a Managed Care Plan (MCP), like Kaiser or Health Net, and many don't realize it. We can't verify or bill without the MCP name. Ask your client to check for MCP paperwork or call Medi-Cal to confirm.

Some clients start on Fee-for-Service (straight) Medi-Cal and get moved into an MCP within their first few months. Once that happens, we need the MCP info to keep billing. Check in with your client if their status changes.

Loula covers the cost of visits submitted before the lapse. Once coverage lapses, you can't submit new visits until your client has active, eligible coverage again.

Health plans don't always share which plan is primary, even when we call directly. Only an EOB or denial letter from the primary plan confirms this, which is why we need your help getting that documentation.

Ask your client about any coverage changes at intake and throughout care, and let us know right away. This includes new plans, lapses, and MCP details.

The Medi-Cal Benefits Identification Card (BIC), the one with the gold poppies, only confirms someone qualifies for Medi-Cal. It doesn't show which Managed Care Plan they're enrolled in, so we can't use it to verify or bill.

An eligibility check is a snapshot: is this client active for this service on this date? Insurance verification is different. It's an ongoing process we run at multiple points in a client's care, so you can keep providing services and getting paid.

We get results from health plans through the Electronic Data Interchange (EDI), a standardized format health plans use to share coverage data. Sometimes what shows up in a health plan's portal doesn't match what comes through EDI. This happens because health plans often store information across multiple systems that aren't fully in sync with each other.

Because of this, verification can take time. Your client's profile shows a verification-initiated date, so you know when the process started.

Loula is confirming this client's insurance for the first time. No action needed yet. You'll get an email once verification completes.

Loula is re-checking a client whose insurance was previously active, either because something changed or as part of routine re-verification. No action needed while this is in progress.

You'll get three emails during this process:

It's normal for a client to move back into Pending during re-verification, even if they were Active before. This doesn't mean something went wrong.

Groups: all shared doulas and group admins receive these emails, except onboarding-only members.

This client's insurance has been verified. You'll get an email the first time a client moves from Verifying to Active.

Groups: all shared doulas and group admins receive this email, except onboarding-only members.

Something on file needs a closer look before verification can complete. Common reasons include:

Check the client's profile for the specific reason, correct the information, and Loula will re-verify automatically. You'll get an email when this status is set.

This client has more than one insurance plan, and Loula needs documentation showing which plan is primary. See Section 5: Coordination of Benefits for what to do next. You'll get an email when this status is set.

This client's Medi-Cal is managed through a Managed Care Plan (MCP), like Kaiser or Health Net, and Loula needs more information to credential and bill correctly. Check the client's profile for what's missing. You'll get an email when this status is set.

Groups: all shared doulas and group admins receive these Action Needed emails, except onboarding-only members.

During verification or re-verification, we found that the plan the client was created with isn't their primary insurance. See Section 5 for the special case where a COB denial leads to this status. You'll get an email when this status is set.

This client's insurance is no longer active. You'll get an email when this status is set.

Confirm with your client whether they have updated coverage, and replace their coverage on file. If they have new coverage with a different health plan, Loula must be contracted with that plan and you must be credentialed with it before you can bill for it.

During verification we found this client's coverage comes through a Managed Care Plan that you're not currently credentialed with. You will not be able to serve this client.

If the plan is in-network with Loula, you can submit a request to get credentialed with the plan through your Loula's portal's Credentialing page so that you can serve future clients with this plan. Do note that depending on the plan, this process may take 3-6 months.
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If the plan is out-of-network with Loula, like the Kaiser Self-Funded plan, you will not be able to bill for the client through Loula.

This client's plan type doesn't cover doula services. You'll get an email when this status is set.

Groups: all shared doulas and group admins receive these Ineligible emails, except onboarding-only members.

COB order documentation is proof of which plan is primary and which is secondary for your client. It's what allows Loula to bill correctly.

This applies any time a client has two insurance plans. Loula can only bill the primary plan, and that plan has to be one Loula serves and one the doula is credentialed with.

Medi-Cal is always the payer of last resort. If a client has any other insurance, Medi-Cal is never primary.

If you've indicated your client has more than one coverage, obtaining COB documentation is a manual step on your end. This differs from most verification steps, where Loula handles the work for you.

There isn't one standard "COB letter." It's a letter from the client's health plan, an Explanation of Benefits (EOB) or denial letter, showing what the primary plan did or didn't cover.

What you'll need to request it:

Contact the client's primary health plan directly, through their provider portal, phone line, or fax, and ask for an EOB or denial letter for the date of service in question. An eligibility check alone usually isn't enough.

If Loula receives a COB denial from the primary payer, the client's status automatically moves to Ineligible (COB Order). Note that there's usually a delay between when the denial happens and when Loula finds out, so the status update may lag behind the actual denial. You'll get the same ineligible email as any other Ineligible (COB Order) case.

Groups: all shared doulas and group admins receive this email, except onboarding-only members.

Your Clients page sorts every client into one of four buckets, so you know who you can submit visits for and what needs your attention:

Both mean you can't submit visits yet, but the difference is whether there's something for you to do.

It's normal for a client to move back into Pending during re-verification, even if they were Active before. This doesn't mean something went wrong.

If you're not actively serving a client, or their insurance is ineligible or lapsed with no update in sight, mark them Inactive. This keeps your list clean and makes it easy to see who actually needs action from you.

Most Medi-Cal clients get their coverage through a Managed Care Plan (MCP), like Kaiser or Health Net, rather than straight from the state. This is a common source of confusion for both clients and doulas.

Clients often don't know the name of their MCP. They may say they have "Medi-Cal" when they actually have a specific plan, like Partnership. Doulas can get confused too: seeing "Kaiser" might make you assume a client has Commercial insurance, when they actually have Medi-Cal through Kaiser.

To verify and bill correctly, we need your client's MCP name, not their Medi-Cal Benefits Identification Card (BIC), the card with the gold poppies. The BIC only confirms Medi-Cal eligibility. It doesn't tell us which plan to bill, so we can't verify or bill coverage from the BIC alone.

In rare cases, a client has Fee-for-Service Medi-Cal (also called straight or regular Medi-Cal), meaning Loula bills DHCS directly instead of an MCP.