Billing Insurance Tab

The Insurance tab lists all insurances associated with the selected visit and allows the user to add, update, delete or re-rank the insurances assigned to a visit. It allows insurances to be verified, while subscriber, bill code, coverage, and exclusion information can also be managed.

A visit can have multiple insurances with the same or different rankings, which determine the order in which insurances are billed. Insurances with different ranking numbers can have overlapping dates, but any insurances with the same rank (for example, Rank 1) cannot have overlapping dates. Insurance rankings cannot be 0 or negatives, and there cannot be a gap between multiple insurances, meaning you cannot have a Rank 2 insurance without a Rank 1 insurance.

The Verified? field in the list can update in real time if using electronic insurance verification.

To add an insurance, follow these steps:

1. Click the Add button . A row is added to the list and the detail fields are enabled. The row will have a corresponding rank, meaning if it is the first insurance added to the visit, it will be Rank 1. The Policy Begin field defaults to the current date.
2. Subscriber Relationship – Click to select one of the following as the insurance subscriber (the person who subscribes to the insurance):
   • Patient – This is the default. Patient information is automatically displayed in the Subscriber child tab, which is disabled for editing.
   • Guarantor – Guarantor information is automatically displayed in the Subscriber child tab, which is disabled for editing.
   • Other – No information is displayed in the Subscriber child tab, which is enabled for editing.

3. Insurance – Enter the insurance and plan IDs into the first two fields or an insurance plan description in the autocomplete field (clicking a suggested description to select it). The address and phone fields will also populate with insurance plan information.
4. Override – Based on settings, the Override checkbox may be enabled. The Override option allows insurance company information to be edited in this window for the specific visit, but it does not update the insurance company’s information in the system. Insurance name, address, and phone information can be overwritten if configured in Insurance Maintenance.

5. Policy – Enter the policy number into the field.

6. Group No – Enter the insurance group number.
7. Group Name – Enter the insurance group name.
8. Billing Hold – Click the drop-down menu and select a reason for the account to be placed on hold for billing purposes. No billing will take place on the visit, and the visit will be listed on the Billing Exceptions Report until the hold is removed.
9. Ins. Estimate – Enter the estimated insurance payment.
10. Release of Info – Click the drop-down menu and select an option:
    • Yes – Patient information can be released to other physicians or healthcare organizations.
    • No – Patient information cannot be released to other physicians or healthcare organizations.
    • Restricted – Restricted patient information can be released to other physicians or healthcare organizations.

11. F/C – Displays the financial class for the insurance’s primary payer.
12. Claim Code – Displays the insurance’s claim code.
13. Policy Begin – Defaults to the current date. Click the field to enter the insurance’s effective beginning date directly or to select from a calendar.
14. Policy End – Click the field to enter the insurance’s effective ending date directly or to select from a calendar. Insurance plans with active dates are carried forward to future visits.
15. Benefits Assigned – Check to assign payment to the facility/provider. Uncheck if payment is to be assigned elsewhere.
16. Indigent – Check to identify the patient as indigent for reporting purposes.

17. Combine Mother/Baby Bill – Check to combine the charges and credits of the mother’s visit along with the baby’s visit into a single bill. Uncheck to generate two separate bills. Both the mother’s and baby’s insurances must have this checked in order to combine the bill.
18. Verified – Check to designate the insurance as verified. The Date and By fields automatically display the date, time, and user who verified in the insurance, and the Verified? field in the list is updated.

19. Click Save.

Update Insurance Plans

To update an insurance plan, follow these steps:

1. Click on an insurance in the list to select it.
2. Update any fields, as needed.
3. Click Save.

Delete Insurance Plans

To delete an insurance plan, follow these steps:

1. Click on an insurance in the list to select it.
2. Click the Delete button . The insurance is removed from the list.
3. Click Save.

Rank Insurances

Insurances are ranked automatically based on the chronological order in which they are originally assigned to the visit. If the patient has multiple insurances, they can be ranked to change the order of payers on the visit or to split the responsibility on a visit. To rank insurances, follow these steps:

1. Click on an insurance in the list to select it.

2. Click in the rank field and enter a new ranking number or click the up  arrow or down  arrow to re-rank the insurance.

3. Click Save.

Subscriber

The Subscriber tab allows a subscriber’s demographic and employer information to be added or updated if the Other option is selected in the Subscriber Relationship field on the Insurance tab. If Patient or Guarantor is selected on the Insurance tab, that person’s information defaults in the Subscriber child tab. The subscriber is the person who holds the insurance that is being applied to the visit.

To complete the subscriber information, follow these steps:

1. Rel to Pat – Click the dropdown and select the subscriber’s relationship to the patient. If the subscriber is someone who was entered as a Relative, then their information automatically displays when selected. If the subscriber is not a relative, the remaining steps must be completed.
2. SSN – Enter the person’s Social Security number.
3. Last, First, and MI – Enter the name information. The first and last name fields are required.
4. Sex – Click the dropdown and select a sex.
5. DOB – Click the field to enter the birth date directly or to select from a calendar. The Age field is automatically calculated.
6. Address Same as Patient – Check if the person’s address is the same as the patient’s. The address information is automatically populated based on the patient’s information.
7. Street – Enter the mailing address. Information can be entered on multiple lines.
8. City – Begin to enter the city name. An autocomplete list with all cities (listed with state and zip code) matching the entered letters displays (after two letters are entered). Click on a description to select it. The City, State, and Zip Cd fields are automatically populated with the selected city information.
9. State – Click the dropdown and select the state.
10. ZIP Cd – Enter the ZIP code for the address (The City and State fields automatically populate.) or begin to enter the name of the city in the City field. An autocomplete list with all cities matching the entered letters displays (after two letters are entered). Click on a city to select it. The State and ZIP/PC automatically populate.
11. Phone – Enter the phone number, including the area code, into the field.
12. Employer – Enter an employer code in the first field or an employer name in the autocomplete field (clicking a suggested description to select it). The employer address displays along with any defined phone number in the Phone field. The employment date, retired date, occupation, and part-time fields are enabled.
13. Student – Check to designate the patient as a student.
14. Part-Time – Check to designate the patient as a part-time employee.
15. Empl. Date – Click the field to enter the employee’s start date with the employer directly or to select from a calendar.
16. Retired Date – Click the field to enter employee’s retirement date directly or to select from a calendar. This may be needed for Medicare patients.
17. Occupation – Enter the patient’s job title with the employer.
18. Phone – Enter the phone number, including the area code, into the field.

19. Click Save.

Bill Codes

The Bill Codes tab is used to add or update bill codes associated with an insurance plan. The codes display on the UB bill and can affect the reimbursement paid by the payer.

To add a bill code, follow these steps:

1. Click the Add button . A row is added to the list and the Billing Type and Billing Code drop-down menus are enabled. The Billing Type dropdown defaults to Condition Code.

2. Billing Type – Click the drop-down menu and select a billing type:
   • Condition Code – Identifies any conditions that may affect the bill.
   • Value Code – Defines values for specific insurance or treatment items.
   • Occurrence Code – Identifies a significant event and date related to the bill. The same occurrence code can be added multiple times as long as each has a different date.
   • Span Code – Identifies the time frame for an event related to the bill.

3. Billing Code – Click the drop-down menu and select a billing code, which is based on the billing type selected.
4. Set the dates or value amount, depending on the billing type:
   • Occ. Date – This field is active for occurrence and occurrence span codes. Enter the date directly or select from a calendar the date the occurrence happened or the start date of an occurrence span.
   • Occ. End Date – This field is active for occurrence span codes. Enter the date directly or select from a calendar for the end date of an occurrence span.
   • Value Code Amt – This field is active for value codes. Enter the value amount of the code.

5. Click Save.

Update Bill Codes

To update a bill code, follow these steps:

1. Click on a bill code in the list to select it.

2. The Billing Type and Billing Code cannot be edited. Make any necessary changes to the Occurrence Date, Occurrence End Date, or Value Code Amount.
3. Click Save.

Delete Bill Codes

To delete a bill code, follow these steps:

1. Click on a bill code in the list to select it.
2. Click the Delete button . The bill code is deleted from the list.
3. Click Save.

Coverages

The Coverages tab allows the user to manage deductible, pre-certification, and Medicare covered days information for the selected insurance. The Covered Days section fields are only enabled if the selected insurance is a Medicare insurance.

 

To complete the Coverages tab, follow these steps:

1. Ded. Amt – Enter a dollar amount for the total deductible.
2. Deductible Satisfied – Check if the patient has met the deductible for the visit.
3. Ded. Met Amt – Enter a dollar amount for the deductible met so far.
4. Benefit ID – The field defaults to the Benefit ID assigned to the insurance plan in Insurance Maintenance.
5. Co-Pay – Enter a dollar amount paid by the patient as a co-pay.
6. Coverage Levels – Click to set and update room charge limits and up to three insurance coverage levels for an insurance plan.
7. Pre-Auth No – Enter the insurance pre-authorization number if one is required (as selected for the plan in Insurance Maintenance). Any verification phone number and/or contact associated with the insurance display in the Phone and Contact fields.
8. Phone – Enter the phone number, including the area code, into the field.
9. Contact – Enter the insurance contact person’s name.

10. Click Save.

Covered Days

The Covered Days section defines the amount of Medicare-covered days available to the patient and can provide authorization information on the lifetime reserve amounts. Medicare has a defined number of covered benefit days for a visit. Additionally, each patient has a lifetime reserve of covered days. The lifetime reserve days may be used to cover additional non-covered days for a visit that exceeds that standard benefit. These fields are only enabled for an insurance that has the Medicare checkbox checked in Insurance Maintenance.

To complete the Covered Days section, follow these steps:

1. Full Coverage – Enter the number of full coverage days.
2. Co-Ins – Enter the number of co-insurance coverage days.
3. Click Save.

Coverage Levels

The Coverage Levels option is used to set and update room charge limits and up to three insurance coverage levels for an insurance plan. The levels include the percentage covered and the patient’s maximum out-of-pocket expense. This information is used in calculating estimated insurance and self-pay amounts.

Room/Bed Charges Section

The Room/Bed Charges section allows the entry of the maximum amount of dollars the insurance will pay for a specific room type.

To complete the Room/Bed section, follow these steps:

1. Semi-Prvt Limit – Enter the maximum amount of dollars for this room type.
2. Private Limit – Enter the maximum amount of dollars for this room type.
3. Special Limit – Enter the maximum amount of dollars for this room type.
4. Click Save.

Levels Section

The Levels section allows coverage percentages covered by the insurance and the patient’s maximum out-of-pocket expenses for the insurance.

To complete the Levels section, follow these steps:

1. Click on a level to select it. The Percent Covered and Maximum OOP fields activate.
2. Percent Covered – Enter the percentage covered by the insurance plan.
3. Maximum OOP – Enter the patient’s maximum out-of-pocket expense amount.
4. Click Save.

Exclusions

The Exclusions tab is used to add or remove revenue codes for items that are not covered under the insurance plan.

To add an exclusion, follow these steps:

1. Click the Add button . A row is added to the list and the Rev Id field is enabled.
2. Rev Id – Enter a revenue ID in the first field or a revenue ID description in the autocomplete field (clicking a suggested description to select it).

3. Click Save.

Delete Exclusions

To delete an exclusion, follow these steps:

1. Click on an exclusion in the list to select it.
2. Click the Delete button . The exclusion is deleted from the list.
3. Click Save.

Authorizations

The Authorizations tab is used to enter insurance authorization information, complete approval and certifier information, and track referring physician information for the selected insurance. If this tab is used, then the role should not have the Authorization Detail and Utilization Review rights granted, and the Global Registry keys UR_MANAGED_CARE_NOT_REQUIRED and UR_METHOD_NOT_REQUIRED should be enabled (Value 1 = 1).

 

1. Click the Add button . A row is added to the list and the detail fields are enabled.
2. Authorization No – Enter the alphanumeric authorization number provided by the insurance company.
3. Status – Click the dropdown and select a status. The authorization must have a status of Approved in order to be processed by Billing. The other options (Appealed, Denied, and Doctor Review) are informational for utilization reviewers.
4. Approved From/Approved To – Click the field to enter the date directly or click to select a date from a calendar.
5. Units Auth – Enter the number of authorized units.
6. Units Used – This field is not used at this time.
7. Certifier – Enter the name of the person who certified the insurance.
8. Referring Phys – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it). If the visit does not already have a referring physician, this entry will be saved as the visit’s referring physician.

9. Click Save.

Update Authorization

To update authorization information, follow these steps:

1. Click on an authorization in the Authorizations list to select it.
2. Make any necessary changes.
3. Click Save.

Delete Authorization

To delete and authorization, follow these steps:

1. Click on an authorization in the Authorizations list to select it.
2. Click the Delete button. The authorization is removed from the list.
3. Click Save.