Patient's Insurance

PATinsuranceV16

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NEVER change an insurance company #. ALWAYS add a new insurance if the patient is covered by a different insurance company. The insurance company that is no longer valid should be expired and marked to be deleted. If an insurance was used, it should be expired. If an insurance has not been used, it can be deactivated. Having an office change an insurance company # of an existing insurance on the account can cause problems in superbills, scheduling, posting, ledger and billing. The changed insurance will not be updated in the superbill or appointment record. However, if the insurance has never been used either on a referral or on a charge, payment or adjustment, the insurance company # can be changed without detrimental ramifications.

•	MEDENT will not allow an Insurance plan to be selected that does not cover the Patient on the date of the appointment.

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MEDENT will recheck the coverage if the appointment date is changed. (This will also ensure coverage for Superbills that are not linked to a scheduling record.) These records will also be checked if the plan's effective or expiration date changes, or if the Covered flag is set to No. Labs, x-rays and orders will also be checked based on the entered expiration date or the not covered flag to change the Insurance on those as well.

•	If the Superbills or appointment records are no longer covered, the Insurance plan will be unselected from those records, and a popup window will notify the User. This update will be logged to an exception file called tmp/InsDeSelect.log.

•	For Superbills, the change will be logged in the Superbills log.

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An option will offer to update a Patient's Superbills and scheduling records with the new primary Insurance plan if a Patient's primary Insurance plan changes. This could occur if the Patient's coverage order in the "Member Screen" or "All Member Screen" changes, or if the primary Insurance plan is deleted.

•	The maximum # of Insurance plans allowed is 100. This includes deactivated plans even though those are not in the count of Insurance plans on the Patient information screen.

•	InsCo: This number is assigned to the Insurance in the Insurance Company Master File. Click on the link to view the entire list of Insurance Companies found in the Master File. The Insurance Companies will display both in alphabetical and numerical order.

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AB: Assign Benefits. Authorize payment of medical benefits to the provider. Information in field 13 of the CMS forms is affected by this field. A "Y"or "N" is defaulted from the Insurance Company Master File. If the field is blank at the Master File level, you will be forced to enter a "Y"or "N" at the Patient level. This field should never be blank.

Note: The AB flag controls the release of statements, as the AA flag did in previous versions. If you have a Y in the AB field we will not send a statement unless the Days to Personal criteria has been exceeded. Days to Personal is set at each individual Insurance in the Master File. This can be based on number of days from the claim process date or service date. This option is found at Patient Billing Options à #28 Set Personal Dates Option.

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Y: Payment is requested to be sent directly to the office. A Yes indicates you have a signed release from the Patient for payments to be assigned to the provider. Note: This can be Yes even if the office doesn't par with the Insurance. The goal is to try to have the company send the Insurance payment directly to the practice instead of the Patient.

•	N: Payment will be sent to the subscriber.

•	AA: Accept Assignment. Does Practice Accept Assignment with this Insurance Company. Information in fields 12 and 27 of theCMS form are affected by this field.

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Y: All Providers in the Practice Accept Assignment. Charges in the A/R section of the Ledger Card will appear on the A/A line. The Insurance Post program will calculate an Accept Assignment adjustment for the difference between the charge amount and the Allowed amount. Answer Yes if the Doctors have a contracted agreement with this carrier. This way the adjustment will be made so you will bill the Patients the difference between this Insurance carrier's approved amount and what they paid. Warning: A few carriers such as Medicare and Champus/Tricare hold the office to this field, literally when answered Yes, as far as accepting the contractual terms of Accepting Assignment with them.

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y: Selected Providers in the Practice Accept Assignment. The Insurance Post program will calculate an adjustment for the difference between the charge amount and the Allowed amount ONLY for the selected Doctors that have a contracted agreement with this carrier. This way the adjustment will be made so you will bill the Patients the difference between this Insurance carrier's approved amount and what they paid.

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N: This Practice does not Accept Assignment/ Charges in the A/R section of the Ledger Card will appear on the Personal '*' line. No adjustment being calculated. Answer No if the Doctors do not have a contracted agreement with this Insurance carrier. This way no adjustment will be made and you will be able to bill the Patients the difference between your 'usual and customary fees' and the amount the Insurance Company pays.

Note:

•	If the claim is subject to copay/coinsurance and or deductible MEDENT will not adjust these amounts off.

•	After the flag is changed, this utility must be run: Reset Insurance File Accept Assignment Flags. If the activity records need to be changed, run this utility second: Reset Activity File Accept Assignment Flags

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Mgp: Medigap: Enter Y if the Insurance Company entered is secondary to Medicare and is a Medigap company. The Medigap # will pull from the Insurance screen if it was entered. It can be modified through Insurance Company Master File. If the Insurance Company was a free text enter the MgpID in the Patient Insurance screen. The Mgp field should be left N if Claim Forward (CF) is set to Y.

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CF: Information will default from the Insurance Company Master File but can only be changed to Y if set to Y at the Master file level. Claim forwarding is for companies that are secondary to Medicare and Medicare agrees to forward the claims automatically. If this field is set to Y this will be the default when manually posting payments in the Medicare Post. Note: When payments are posted via Autopost, MEDENT does not look at this field it goes by the information supplied in the Remittance File.

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MSP: Medicare Secondary Payer: When Medicare is the secondary Insurance Company, claims can be sent electronically to Medicare. On the Primary Insurance Company screen set the MSP to Y to indicate that Medicare is the secondary Insurance to this company. If this field is marked Y, when posting payments from the primary Insurance, there is a prompt for the approved amount.

•	Claims being submitted to Medicare as the Secondary payer can occur when a Patient is still of working age but has Medicare benefits due to a disability, or for several other reasons.

•	ANSI 4010 version: Will no longer require an MSP Payor ID number to be submitted on MSP claims (this field was found on the Insurance screen of the Patient's primary Insurance).

•	Required Fields:

1.	Primary Insurance needs to be flagged as an MSP account:

2.	When the flag is changed to Y and the user hits / [Enter], a box will pop up where the user can enter the MSP ID # and MSP Ins Type. Note: Payor ID only required when billing claims to Upstate Medicare in the NSF format

Click OK

A box with the account members will pop up. The user can enter the MSP type for all members. If the user does not enter the MSP type and hits [Enter], there will be a prompt for the user to enter an MSP type. If the user hits [Enter] again, the screen will exit back to the Patient's Insurance screen. See Also: MSP Type

5.	In the Ledger Card, MSP claims must have the approved/deductible information on the payment line from the primary Insurance

•	Contact: The name and phone number of the Insurance Company representative. This information defaults from the Insurance Company Master File. If a free text Insurance, nothing is defaulted and the information can be changed per Patient.

•	: View/import Patient's Insurance cards using the ScanShell 800N / 800R / 800NR scanner. See Also: Insurance/Business Card Scanning.

•	The Insurance Company's address is defaulted from the Insurance Company Master File. If the Insurance Company is a free text company, enter the Insurance information from the Patient's Insurance card.

Insurance Company Address Format:

Insurance Company Name

Street Address

City, NY 00000

•	If this address format is not followed, the electronic claims will reject before they are sent out. Note: If the Addr2 line is used, this will not transmit in any format:

•	Insured: The Primary Patient defaults into this field. The Insurance Company setup determines what pulls in here. See Also: Insurance Company Master File à Patient is Ins'd field. Other Insured will be listed as the last member if this option is available.

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To edit this field, click on the Insured link and click on the appropriate member (or enter the # next to the Member Name or 0 for Other). Enter the Insured's Name, Address, City, State, Zip Code, Birthday, Sex, and Social Security Number. If the Social Security Number is not documented, this sometimes causes rejections when trying to submit the Insurance. Note: If entering a person who is NOT on the account, the Addr 2 field is non-usable. This field does not get sent via electronic billing, and therefore not editable. Information from the Primary Patient will automatically pull in.

Note: The SS # field no longer needs to be entered for electronic billing.

•	ID #: Insured's ID #

•	If the insured is a member on the account, this number will pull from the member information.

•	If the insured is entered as OTHER, this field should be filled in.

•	If the Insurance Company Master File has Patient is Ins'd = Y, this number is not required.

•	Employer, Addr, City: The Insured's Employer Information. This is not a mandatory field, unique per account.

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CH: Indicates the number of the Clearinghouse for sending Electronic Claims. This information is defaulted from the Insurance Company Master File. This field can be setup for the Emdeon clearinghouse at the Patient level if the Insurance Company type is Free text commercial (T). If entered here, then the Emdeon Payor ID must be entered as well. Note: If it's a free text company and the CH field is black, then go to the Insurance Company Master File > Edit/View and make sure the Payor ID field is blank. Often a client puts the generic 98999 for Private Insurance. If there is a Payor ID at the Master File level, it can't be set at the Patient level.

•	Champ / Grade / Status: This area is for Champus documentation. Enter the Branch of Service. Next to Grade enter the Rank. Under Status enter if Active, Retired, or Deceased. The Champ field is required for billing Champus/Tricare. See Also: Military Pay Grades

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PayID: This is a required field. 98999 may be used for companies that do not have a specific Payor ID. Click this link to access a list of Insurance Companies and their Payor ID's. This list is accessible for free text companies that do not have a Payor ID entered at the master file level. The list will be sorted alphabetically and will begin with companies matching the name of the free text Insurance Company. There is a button for No Payor Id. If this is chosen, 98999 will be entered for the PayID. If the field is bypassed and nothing entered, 98999 will default as the PayID when exiting the company. If the Insurance Company is set to send to a clearinghouse at either the master file or Patient level, or the company type is T1 or T2, 98999 is not an acceptable Payor ID. You will not be allowed to exit the company until an acceptable Payor ID is entered.

•	MSP # / Insurer Type: MSP must be flagged Y. It is no longer required to enter a number in. However, if a number defaults in, it is okay to leave it.

•	NAIC: If the Insurance Company is a free text company and the NAIC code value in the Insurance Company Master File is blank, then the field will be accessible within the Patient's Insurance screen. Otherwise, the value in the Master Files will be displayed but inaccessible from this screen.

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Pay Type: Payor Type Code that is used for PHC4. The first digit must contain one of the following characters: "0123456789". The second digit must contain one of the following characters: "023456789". This field is accessible only if the Insurance Company is free text and the value from the Insurance Company Master File is blank.

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ECS Car Cd: This code is required by some Medicaids (PA, VT, MA, NJ) on the primary Insurance Company when submitting a secondary claims to Medicaid. Click on the link to select and enter the carrier code based on the Insurance Company. Note: If the Insurance Company is a free text company, the ECS Carrier Codes can be entered on the Insurance Company in the Master Files, as well as in the Patient Insurance to make changes to the Carrier Code. If the Insurance Company is NOT a free-text, then the Carrier Codes must be entered at the Insurance Company Master File. At the Patient level, they can be viewed, but not changed.

•	Group#: Carrier or Patient's Group #. For Worker's Comp Insurance, this field is used to enter the WCB#.

•	InsT: Select the type of Insurance:

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Federal

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State

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HMO

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Commercial

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Workers Compensation / No Fault

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Free Text Workers Compensation / No Fault

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Free Text Commercial

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Article 28

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Collection Agency

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PlnNa: Insurance Company Plan Name. If the Insurance is a Medicaid Insurance, click

to display a list of source or resource codes that are valid for the selected state in the Insurance Company type, e.g. for Medicaid-NY only the NY MO Codes as choices will show. The number input will print in the 23B field (Payment source code) on form#22. This is not a field that will transmit electronically. It will only print on paper. These codes can be found in the Medicaid/Medical Assistance manual: NY MO Codes, PA Resource Code, OH Pay Source Code

PATinsmember

•	Click anywhere on the Member line to access the Member's information screen. This would be the same as clicking the Members button.

•	New Patient: The Member Identification screen shows up on initial registration. Enter any edits on the Patient Information Insurance Company.

•	Id#: Member Identification #. Click on this link and a browser window will open up to the Insurance website (If a website is set up in Insurance Company Master File à Click More button next to the Contact name to enter the website address). Right click on the link for these 2 options:

•	Copy policy number to clipboard: Copy the ID#. It can then be pasted where needed.

•	Launch browser to insurance website...: If a website is set up (Insurance Company Master File à Click More button next to the Contact name to enter the website address) a browser window will open up to the Insurance website.

•	: Click on the magnifying glass to access the patient's insurance eligibility Information. See Also: Insurance Eligibility Information Screen. Note: This icon will only display if the patient's insurance participates in eligibility checking.

•	: Gray means the insurance eligibility request has not been run within the past week. When the cursor hovers over the icon, a tool tip will say Eligibility is out of date.

•	: Green means the patient is covered by the insurance. When the cursor hovers over the icon, a tool tip will say the Status and Copay information.

•	: Red means the patient is not covered by the insurance or the insurance request failed. When the cursor hovers over the icon, a tool tip will say This Patient is Not Covered or Last Updated was Rejected.

•	Seq#: This field only displays when the Insurance is NYS Medicaid. The Patient's Seq# is found on the Patient's Medicaid Insurance Card and is needed to get Patient referrals from Medicaid.

•	Covered: Is the Patient covered by this Insurance.

•	If an Insurance plan has been expired and still has outstanding charges, the covered flag needs to be set to Y in order to be able to rebill the claims.

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If an expired Insurance is also marked for deletion and is linked to an unpaid claim to another Insurance Company, the expired Insurance payment will not send over the claim level information if submitted through ECS. The total amount of the payment from the expired Insurance will go over but not the claim number.

•	If an Insurance plan has been marked as non-covered, then unpaid claims can not be rebilled without changing the covered flag back to Y and entering an order number for the Insurance plan.

•	An Insurance plan on an account should only be marked non-covered for the members on the account that were never covered at all.

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Order: Edit the Insurance Order / Billing Order, e.g. Primary Insurance, Secondary Insurance etc. If an account has more than one Medicare type plan, e.g. DME Medicare, this plan should be listed as the 2nd Insurance. All Medicare plans should be grouped together on the Patient account. The commercial/HMO that is the true secondary plan should be listed as the third plan. MEDENT will not crossover from one Federal plan to another. Note: If an Insurance is marked for deletion and it's order 2, it will skip over and go to Company 3.

•	To change the Insurance Member Order: Click Ins à Select Insurance à Click on the Members name à Change billing order for member.

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If a change is made in the order of Insurances for a member and there are Superbills and Appointments that are affected by this coverage change, the Coverage Change Screen will be displayed so the user can select another Insurance plan to apply to those Superbill/Appointment records (provided there is another plan to switch to.) If there is not another plan to switch to the default logic will handle the situation. The Insurance plan will be selected from all non-closed, current and future Superbills that are linked to a booked appointment. See Also: Insurance Coverage Change Screen

•	Effective: Date Insurance Effective.

•	MSP Type: Medicare Secondary Payer Types of Primary Coverage.

•	Relate: Relationship to the Insured (Carrier) of this Insurance Plan. These include:

(W)ife

(H)usband

(L)ife Partner

(C)hild

(P)arent

(O)ther

(S)elf

•	Expired: Date the Insurance is terminated / expired.

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Onset Date: Enter the Onset Date of the injury the Patient is being seen for. This overrides the onset date in the Patient/Account Member Information screen. The most current date will show in the boxes. Note: Use Other Onset Dates if Patient has multiple Injuries. Other Onset Dates will not appear for Workers Comp/NoFault Insurance Companies.

•	If the onset date is changed on the member screen, when exiting, a new window will come up with a list of current and future Superbills. Any selected Superbills will be updated with the new onset date and reason. When done selecting, click OK at the bottom of the window.

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Accident / Time: When adding onset dates to the member records the user has the ability to make them accident related and choose the accident code. When scheduling an appointment the accident code will be taken from the member record and put into the Superbill. When a Superbill is used in charge entry the accident code is pulled from the Superbill.

•	Time: Enter the Time of Onset for Compensation or NoFault Insurance Company. Note: Time will appear instead of Accident if member record has Workers Compensation or No Fault Insurance Company.

•	Reason: The Reason for this case.

•	1st Service: Enter the Date of 1st Service. Note: When billing Medicare for PT/OT/ST/podiatry charges, an onset date or reason for case is necessary if there is a 1st service date entered on the member record.

•	RDr: Referring Doctor number of the Doctor who referred the Patient to this office.

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State: Enter the 2 character abbreviation for the State where the injury occurred. This field only displays when the Ins Company Type is set to w1, W1 and the M'caid, M'care or BC Facility Claims is set to Y under Other Options. This is needed when billing a Workers Compensation case on the UB04 form, FL 29.

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Buttons:

•	Next Page / [F8]: The fields on this page are not yet active and cannot be used.

•	Log / [F6]: View the log of all activity for this item.

•	/ [F1] (Display List): Provides all the options for selected fields.

•	Members: Access to the Account members. Please see 5. Members above.

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Referrals: The Insurance Company requires the provider to submit a referral or authorization number. Add/edit referrals for each member of the account. Also, track referrals per Patients by authorization number, visits remaining and date of expiration. To include a Patient's closed Referrals, the user can click Include Closed. To only view open referrals, the user would then click Exclude Closed. Note: Once a referral has been closed it can no longer be viewed through the Patient's Insurance. It can be viewed through the Referral Lookup By options. A referral must have an Insurance attached in order to be listed.

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Expire: Enter the date the Insurance has expired for the Primary Patient and/or Account Members. If the Insurance plan is expired and there are Superbills and Appointments that are affected by this coverage change, the Coverage Change Screen will be displayed so that the user can select another Insurance plan to apply to those Superbill/Appointment records (provided there is another plan to switch to.) If there is not another plan to switch to, the default logic will handle the situation. The Insurance plan will be selected from all non-closed, current and future, Superbills that are linked to a booked appointment. See Also: Insurance Coverage Change Screen

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Deactivate: Used to deactivate an Insurance. An Insurance Company cannot be deactivated if there are either unpaid charges flagged to that Insurance or charges with payments from that Insurance in the ledger activity. If this is the case, when clicking on Deactivate, the Insurance Company will be marked to be deactivated. The Insurance Company will be deactivated AFTER all charges with payments from that Insurance Company have been paid off and PURGED to history.

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If the Insurance plan is deactivated and there are Superbills and Appointments that are affected by this coverage change, the Coverage Change Screen will be displayed so that the user can select another Insurance plan to apply to those Superbill/Appointment records (provided there is another plan to switch to.) If there is not another plan to switch to, the Insurance will be removed from the Appointments/Superbills. The Insurance plan will be deselected from all non-closed, current and future Superbills that are linked to a booked appointment. See Also: Insurance Coverage Change Screen

•	A message will appear reminding the user there are open referrals on this Insurance that need to be closed.

•	Activate: If an Insurance is marked as deactivated, the Activate button at the top of the screen, will make this Insurance active again. The coverage flags for each member will need to be reset.

•	Log: View the log of all activity for this item. To see changes in policy #'s and other Member specific information, please click on Members. Choose a Member and view the Member's log.

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The Birthday Rule is endorsed by the National Association of Insurance Commissioners (NAIC). The Birthday Rule states that the plan of the parent whose date of birth (month and day) falls earlier in the calendar year is the primary plan for children on the account. For example, if the father's birth date is June 10 and the mother's birth date is March 28, the mother's plan would be primary. If both parents have the same birth date, the health plan in effect for the longer period of time will be primary.

PATinsurancecoveragechange

•	There are four situations that cause this screen to pop-up:

1.	Insurance Plan becomes Expired:

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In the Insurance member screen (and all member screens) if the effective or expiration date is changed or if the coverage flag is changed from Y to N, all Superbills (that are not closed, that have a current or future date, and that are linked to a booked appointment record), are examined to determine if the plan will still cover the Patient on the appointment date. All Labs, Xrays, and Orders (with a status of Ordered or Scheduled are also checked to determine if the plan will still cover the Patient on the ordered or scheduled date. If not, the Insurance Coverage window pops up (as long as there is one or more Insurance plans available to switch to).

•	The Superbill/Appointment records/Labs/Xrays/Orders that are no longer covered are displayed.

•	The Insurance plans that cover the Patient, (now and in the future), are displayed.

•	The user is prompted to select a new Insurance plan for the Superbill/Appointment records/Labs/Xrays/Orders listed.

•	The user can select all or individual Superbill/Appointment records/Labs/Xrays/Orders to assign the new Insurance plan to.

•	When the user is done making selections, click and the changes are applied.

•	Any Superbill/Appointment records/Labs/Xrays/Orders not selected are handled by the default logic (the Insurance plan will be unselected from them.)

•	If the user selects None the Insurance plan will be unselected from all the Superbill/Appointment records/Labs/Xrays/Orders listed.

2.	Primary Plan Changed:

•	When the primary Insurance plan is changed for a member, all Superbills (that are not closed, that have a current or future date, and that are linked to a booked appointment record) are listed. All Labs, Xrays, and Orders with an Ordered or Scheduled status that contain the plan are also listed.

•	The Insurance plans that cover the Patient, (now and in the future), are displayed.

•	The user is prompted to select an Insurance plan for the Superbill/Appointment records/Labs/Xrays/Orders listed. (They can choose to keep the same plan; it is still valid just no longer primary.)

•	The user can select all or individual Superbill/Appointment records/Labs/Xrays/Orders to assign the Insurance plan to.

•	When the user is done making selections, click and the changes are applied.

•	Any Superbill/Appointment records/Labs/Xrays/Orders not selected remain unchanged.

3.	Adding New Insurance Plan:

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When a new Insurance plan is added to an account, MEDENT will search for Superbills (that are not closed, that have a current or future date, and that are linked to a booked appointment record) for each Patient. All Labs, Xrays, and Orders with an Ordered or Scheduled status that do not have any Insurance are also searched for. If any are found they will be listed. The user can choose to apply the new plan to them or leave them without insurance info.

4.	Deletion of an Insurance Plan:

•	When deleting an Insurance plan, the non-closed, current/future, Superbills, which are linked to a booked appointment, and Labs, Xrays, and Orders with a status of Ordered or Scheduled that contain the plan will be displayed and the user may change the Insurance plan (Graphical MEDENT only.)

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The plan will be unselected from any Superbill/Appointment records/Labs/Xrays/Orders (that were not changed by the above logic), regardless of status or appointment date or ordered/scheduled date. This will prevent the possibility of the old (obsolete) Insurance record number pointing to a different plan if one is added later on.

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A pop-up message will indicate how many Superbill/Appointment records/Labs/Xrays/Orders the plan was unselected from. This number may not be the same as the number of Superbill/Appointment records/Labs/Xrays/Orders that were unchanged on the Coverage Screen. That is because the Coverage Screen only displays those records that meet the desired criteria (non-closed, current/future, Superbills, which are linked to a booked appointment, or Ordered or Scheduled Labs/Xrays/Orders). Also, the records displayed on the Coverage Screen can represent both a Superbill and an Appointment record or just a Superbill record or Ordered or Scheduled Labs/Xrays/Orders.

Troubleshooting - Patient Insurance

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