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. If the insurance is set up for electronic insurance verification, the Verify button will be enabled and can be used to manually create an EDI 270 insurance verification request. The Transaction Service then transmits the 270 request to the payer. When configured, a popup window can display real-time updates of the verification status.
To add an insurance, follow these steps:
Note: This box may be checked automatically if the Verify button was clicked and the electronic insurance verification request was returned and approved.
To update an insurance plan, follow these steps:
To delete an insurance plan, follow these steps:
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:
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:
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:
To update a bill code, follow these steps:
To delete a bill code, follow these steps:
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:
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:
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.
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:
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:
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:
To delete an exclusion, follow these steps:
The Pharmacy tab is used to add or update information needed to interface with external pharmacy systems. Insurance plans can be configured to require pharmacy information in Insurance Maintenance.
To add pharmacy information, follow these steps:
To update pharmacy information, follow these steps:
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).
To update authorization information, follow these steps:
To delete and authorization, follow these steps:
The Electronic Insurance Verification Status tab is used to display real-time verification information for an insurance that is set up for electronic verification. The tab displays the request date, status message, co-pay amount, and error message. When the verification is first started in the Insurance tab, the Status column reads “Scheduled for Processing.” The status will update to an error message or successful “Insurance Verified” message. To view detail on the error message, click the row in the list.