Patient Tab - Insurance

The Insurance tab is where you can record and review information about the patient's benefits. This tab will list any insurance records associated with the Primary or Secondary person on the account. If you wish to add new insurance to a patient, you must add it through the Primary or Secondary screen; it cannot be added here. However, please keep in mind that the primary insurance does NOT have to be added to the Primary tab. 

Use this table to determine which insurance is primary, secondary, and so forth for each patient. The insurance at the top is the primary carrier. Click and drag the insurances to place them in the correct order.

The Enabled checkbox determines whether or not the coverage is active for the patient. This is most frequently used on multi-patient family accounts. For example, if the mother and children were on insurance held by the mother, and the father used his own insurance, you would uncheck the Enabled checkbox for the father's insurance on the Insurance tab for all other patients on the account. On the father's Insurance tab, the mother's insurance would be unchecked.

Much of the insurance data pulls from the primary and secondary tabs, but may be overridden on a per-patient basis.

The Subscriber ID lists the patient-specific ID number for the insurance. By default, this will be the same subscriber number that is entered on the Primary or Secondary tab, but it can be changed if necessary. Once you have changed the ID on the Patient tab, the tie is broken. This means updating the information on the Primary tab will not update it on the Patient tab. To re-establish the tie, delete the Subscriber ID from both the Primary and Patient tabs, and save. Once both fields have been saved with a blank value, the tie is re-established.

The Copay, Deductible and Remaining Coverage tabs indicate information about the patient's insurance coverage, and pull from the insurance Plan reference if a plan is selected. This information can also be edited on the fly.

  • If you do not use insurance estimating, the Deductible amount will remain until it is manually edited. The Remaining Coverage will reduce as you receive insurance payments.
  • If you do use insurance estimating, the Deductible and Remaining Coverage amounts will reduce according to the estimated benefits.

Click the Refresh Remaining Coverage button to refresh benefits, based on the insurance coverage used to date, the information entered in the plan, and the renewal date. Please note that if the patient's remaining coverage or deductible amount are overridden, you will not be able to use the Refresh Remaining Coverage button. Refresh Remaining Coverage always uses the plan coverage and deductible amounts to recalculate the patient's coverage, and will not consider any manually overridden amounts.

Start Date and End Date pull in from the Primary/Secondary tabs but may be manually edited if needed. The Start Date is the date the patient first gained this insurance. If you do not know the specific date, it is sufficient to enter a rough approximation, such as the patient's first visit. This information is not reported on claims, but it is used to allocate balances between the Insurance Portion and Patient Portion. The End Date field should only be used if coverage terminates. For example, if a patient left their employer and was no longer covered by the selected insurance. This field is rarely filled out when you first add insurance to a patient's record.

The Policy # will list the policy or group number associated with the insurance in the Primary or Secondary tab.

Use the Medicare Type menu to select a Medicare as Secondary reason, if applicable.

Below the insurance table, you can indicate the patient's current HIPAA Release status, and enter the HIPAA Release Date, if applicable. This can be set in a default patient record, updated for the whole database through a utility, or overridden on eclaims. 

The Special Insurance checkbox is not reflected on claims, but is used in some reporting.

The Family Planning and EPSDT checkboxes will both be reflected on claims. This information is printed in box 24 H of the CMS-1500 form and box 1 of the ADA form. They are also used on eClaims.

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