Network / Provider / Drug Verification Checklist
Help users verify doctors, hospitals, specialists, pharmacies, prescriptions, referral rules, formularies, and out-of-network limits before a participant relies on a plan.
Purpose
Help users verify doctors, hospitals, specialists, pharmacies, prescriptions, referral rules, formularies, and out-of-network limits before a participant relies on a plan.
When to use
Use during plan shopping, support escalation, renewal education, or when a participant has provider, pharmacy, or medication concerns.
Who should use this
Participant support lane, broker/advisor, HR support, or employee experience owner.
Review boundary
Provider, network, pharmacy, and formulary information can change. Verification supports decision-making but is not a guarantee of future coverage or payment.
Resource sections
Primary care provider
- Verify provider by plan, network, location, and date.
- Confirm whether new-patient status matters.
- Record lookup source/date if retained.
Specialists
- Verify key specialists separately from primary care.
- Check network and referral requirements.
- Flag uncertain matches for advisor/support review.
Hospitals and health systems
- Verify preferred hospitals and health systems.
- Check facility versus physician network distinctions.
- Document source/date note.
Pharmacies
- Check preferred pharmacy participation.
- Flag mail-order or specialty pharmacy issues.
- Record source/date if retained.
Prescription drugs and formulary tiers
- Verify drug name, dosage, formulary status, and tier.
- Flag generic/substitution questions for appropriate support.
- Avoid guaranteeing coverage.
Prior authorization or step therapy
- Check prior authorization, quantity limits, or step therapy markers.
- Route complex drug issues.
- Retain notes under approved workflow.
Referral rules
- Confirm whether referrals are required.
- Explain plan-type implications in general terms.
- Route plan-specific questions to licensed support.
Out-of-network limits
- Identify whether out-of-network care is covered or limited.
- Flag emergency/travel questions.
- Document participant reminder.
Service area and travel considerations
- Confirm service area and travel implications.
- Flag split-residence or dependent-location issues.
- Route unusual facts.
Verification date and source
- Record lookup date, source, and any disclaimer.
- Retain screenshot/reference only if workflow allows.
- Link support or advisor note.
Evidence to retain
- Provider lookup source/date - Retain with the audit file, evidence map, or review record as applicable.
- Drug lookup source/date - Retain with the audit file, evidence map, or review record as applicable.
- Pharmacy/source notes - Retain with the audit file, evidence map, or review record as applicable.
- Screenshot or reference note, if allowed by workflow - Retain with the audit file, evidence map, or review record as applicable.
- Advisor/support note - Retain with the audit file, evidence map, or review record as applicable.
- Participant confirmation note - Retain with the audit file, evidence map, or review record as applicable.
Evidence is not saved in this static version. Assign an owner, repeat the process consistently, review exceptions, explain the rationale, and retain copies in the employer file or local project record.
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No database records or server-side files are created. Use these browser-only actions to retain a local copy.
Provider, network, pharmacy, and formulary information can change. Verification supports decision-making but is not a guarantee of future coverage or payment.