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The Plan Maintenance - Details tab maintains contract, network, payment and other control information about a plan. The information maintained about payment and adjustment calculations allows the user to predefine payment and adjustment types and calculation options so that payment entry will be easier and more controllable by the manager with less information left up to the user.
Account Class
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When adding a New Patient, the Account Class specified on the patient's Primary Insurance Plan will default into the patient's account class. This will override the default account class from the Practice Defaults Tab. If the patient's account class is overridden by the user, the Plan Account Class will not be loaded.
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Report As
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The plan description displayed on patient statements
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Claims Options
Report Full Charge on Primary Insurance Claim
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Indicates that the full charge should be reported on claims
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Report Allowed Charge on Primary Insurance Claim
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Indicates that the allowed charge should be reported on claims, usually as the result of performing the write-off on Charge Entry
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Network Details
Network Name
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Enter/Select the Network Name. This is used for reporting purposes.
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In-Network
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Captures deductible and coinsurance information about in-network services including:
These values do not perform any special processing functions in MedSuite. However they may be used to verify that proper payment calculation has been made.
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Out-of-Network
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Captures deductible and coinsurance information about out-of-network services including:
These values do not perform any special processing functions in MedSuite. However they may be used to verify that proper payment calculation has been made.
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Payment Distributions
Payment
Payment Type
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Enter/select the payment type to be used for the plan
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Approved
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Enter/select how the approved is used on payments for the plan:
| • | Allowed Amount (Default to the allowed amount) |
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Deductible
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Enter/select how the deductible and co-pays are used on payments for the plan:
| • | Entered by the User - If selected the system will enable the Co-pay fields in payment entry (Insurance & Bulk) screens but does not require the user to enter co-pay or deductible. |
| • | Not Used - If selected the system will disable the Co-pay fields in the payment entry (Insurance & Bulk) screens. |
Note: The Co-pay fields that are captured in Payment Entry are displayed in the Activity View of the Ledger. A true co-pay (patient payment) needs to be entered on the Visit or as a payment in Self Payment Entry. The Co-pay fields in Insurance and Bulk Payment Entry screens are only recorded in the Ledger for use in a follow-up situation. They are informational only.
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Payment
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Enter/select how the payment is calculated on payments for the plan:
| • | Calc = Approved - Deduct @ Pct |
| • | Calc = Billed - Deduct @ Pct |
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Pct
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Enter the percentage to apply to the payment calculation (above)
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Primary Adjustment
Adj Type
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Enter/select the primary adjustment type to be used for the plan
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Calculation
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Enter/select how the adjustment is calculated for the plan:
| • | Adjustment = Billed - Approved |
| • | Adjustment = Billed - Allowed |
| • | Adjustment = Billed - Paid |
| • | Adjustment = Approved - Paid |
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Secondary Adjustment
Adj Type
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Enter/select the secondary adjustment type to be used for the plan
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Calculation
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Enter/select how the adjustment is calculated for the plan:
| • | Adjustment = Allowed - Approved |
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Pre-Authorizations
Pre-Authorize Hospital-Based Services
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Indicates that hospital-based services should be pre-authorized. If a visit occurs at a Location that has a Service Place that has a place of service code of 20, 21, 22, 23, 24, 25, 26, 27, 28, or 29, the system will require a Prior Authorization No. to be entered on the HCFA tab of the visit. If a user tries to save a visit with the authorization no., an error will be displayed, and the system will position the cursor on the Prior Autho No. field of the visit's HCFA tab.
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Pre-Authorize Office-Based Services
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Indicates that office-based services should be pre-authorized. If a visit occurs at a Location that has a Service Place that has a place of service code OTHER THAN 20, 21, 22, 23, 24, 25, 26, 27, 28, or 29, the system will require a Prior Authorization No. to be entered on the HCFA tab of the visit. If a user tries to save a visit with the authorization no., an error will be displayed, and the system will position the cursor on the Prior Autho No. field of the visit's HCFA tab.
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Request Statement
Special Billing Message
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The billing message that will appear on the informational statements requested for this plan. Optionally, if the Wait for Payment flag is not selected on the Claims tab, this billing message will appear on the account holder's first monthly statement in lieu of the first dunning message, unless a Special Billing Message is specified on the Account Billing tab, which will override the Special Billing Message on the Plan.
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Request Informational Statement
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Indicates that an informational statement will be sent to the account holder when a visit with this plan as primary insurance has been entered. This is used when the Wait for Payment flag is selected on the Claims tab. In that case, the account holder does not receive monthly statements until after the insurance has paid or denied, but a one-time Informational Statement may be requested to let them know that a claim has been filed as a courtesy.
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