Description
Use the Insurance page to view, create, or edit insurance company and plan information, including host codes, routing information, and required patient information. In addition, you may validate insurance companies and plans, as well as inactivate insurance, if appropriate.
Note
You must have the View insurance company right in order to use this page. The system applies insurance company and insurance plan-based routing rules to determine the testing lab for an order choice when appropriate according to the routing rule hierarchy. See the Order Patient Samples topic.
Note
Non-validated insurance companies or plans are not the same as inactive insurance companies or plans. If a company or plan is inactive, the system will not allow you to select it when creating an insurance set, and, when placing an order, you will not be able to assign any patient insurance set that contains an inactive company or plan. If a company or plan is non-validated, you will be able to assign it to any patient insurance set, and you will be able to add the non-validated company or plan to patients' insurance sets; however, the system will only send validated insurance information when it transmits orders.
Access
AdminCenter > Patient Setup > Insurance
You must have the necessary security permissions to access the Insurance page.
Technical Manual
Searching for an Insurance Company or Insurance Plan
| Practice | Select in or enter text into the search-as-you-type field to search for and select a specific practice. By default, the system selects the System Maintained Insurance option for the practice. This option allows you to work with all insurance records that exist in the system. When you search for and select a new practice, the system clears any displayed insurance company and insurance plan search results. |
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| Use System Maintained Insurance | If you have selected a specific practice, select to return to the System Maintained Insurance option. This option allows you to work with all insurance records that exist in the system. |
| Insurance Company | Use the field to filter the Insurance Companies and Plans list by insurance company. Begin typing the name of the insurance company and the list will automatically update. The filter defaults to showing only active companies. Only show companies: Select this checkbox to control whether or not insurance plan information is shown. Insurance plan information will no longer be automatically hidden depending upon which filters have been modified. The Insurance Plan filter can be used to further filter insurance companies even when only companies are being shown on the page. To search for all insurance companies and/or plans, enter an asterisk in either the Insurance Company field or the Insurance Plan field, or both.
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| Insurance Plan | Use the field to filter the Insurance Companies and Plans list by insurance plan. Begin typing the name of the insurance plan and the list will automatically update. The filter defaults to showing only active plans. To search for all insurance companies and/or plans, enter an asterisk in either the Insurance Company field or the Insurance Plan field, or both.
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| Company Filter | Set the options in the Company Filter section to narrow your search. The filters default to showing only active companies. Select or clear the checkboxes for Active, Inactive, Validated, and Non-validated to limit the results of your search to your selections. If you select neither active nor inactive or neither valid nor non-valid for a company, the system does not put any restrictions on that field for the search and it will function as if both are selected. Missing host code for ___: Select the checkbox and select a host code from the drop-down list to display records without host codes for the selected host. |
| Plan Filter | Set the options in the Plan Filter section to narrow your search. The filters default to showing only active plans. Select or clear the checkboxes for Active, Inactive, Validated, and Non-validated for to limit the results of your search to your selections. If you select neither active nor inactive or neither valid nor non-valid for a plan, the system does not put any restrictions on that field for the search and it will function as if both are selected. Missing ___ for ___: Select the checkbox and select either host code or sync info from the drop-down list, followed by selecting a host code or information to sync. Select host code to display records without host codes for the selected host. Select sync info to display records that are not synced with the selected host. |
| Insurance Companies and Plans | If your search generates one or more matches, the matching company or plan names are displayed in the Insurance Companies and Plans list when the page refreshes. Each active insurance record is listed with the company name, plan name, phone number, contact name, contact phone number, company address, and the company and plan active and validation statuses. If you select a different practice, the system clears the list of insurance companies and plans. Select the desired company or plan link to view more details. See "Adding and Editing Insurance Company Information" below. New Insurance Company: Select to add insurance information. This opens a blank record to the Insurance details page. "See Adding and Editing Insurance Company Information" below. Apply All Status Changes: Once you have made your changes, select to have the system save the new active and validated statuses to the appropriate insurance records. Note Applying the changes causes the system to redo the search. This means that if you change the status of a plan or company such that it no longer fits the filter, then it will no longer appear on the page. Active: Select or clear the checkbox in the Company is and/or Plan is columns to indicate the active/inactive statuses for the insurance companies and insurance plans. The system only displays the checkboxes for insurance plans if your search included one or more characters in the Insurance Plan search field (see above). Validated: Select or clear the checkbox in the Company is and/or Plan is columns to indicate the validated/non-validated statuses for the insurance companies and insurance plans. The system only displays the checkbox for insurance plans if your search included one or more characters in the Insurance Plan search field (see above). Note For companies with multiple plans, the Active and Validated checkboxes only appear for the first row on the page on which that insurance company appears. |
Adding and Editing Insurance Company Information
On the Insurance list page, select the New Insurance Company button or select the name of the company or plan to open the Insurance details page to view, add, or edit an insurance company or plan. To edit existing insurance information, select different options or highlight or delete text already displayed in the field, then modify as desired.
| Display page side by side | If there was a plan associated with your selected insurance company, the system displays the Insurance Plan Information section on this page; see "Adding and Editing Insurance Plan Information" below. Select the Display page side by side checkbox to view the insurance company and plan information side by side. Clear the checkbox to view the company information above the plan information. If you choose to view the information side by side, the system displays the Align company and plan sections option. Select the option to have the system space the sections within the company and plan information so that they line up for easier comparison. |
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| Change Log | Select to view the change log for the selected insurance company. See the Change Log topic. You must have the necessary security right to access the Change Log page. |
| Practice | Enter the practice name into the field. |
| Use System Maintained Insurance | If you have selected a specific practice, select to return to the System Maintained Insurance option. This option allows you to work with all insurance records that exist in the system. |
| Company Name | Enter the company name into the field. This field is required. |
| Company ID | Enter the company ID into the field. This field is required. |
| Company ID Type | Enter the type of company ID into the field. |
| Validation Set for Orders | Select the validation set to use for the insurance company from the drop-down list. The system assigns to each new insurance company you create the New Insurance Company Default Validation Set value set in the System Defaults page (see the System Defaults topic) or the selected practice's New Insurance Company Default Validation Set value set in the Practices page (see the Practices topic); however, you may use this field to assign an alternate validation set for the insurance company. If you do not assign a validation set to the insurance company for all practices in the system, then the system will consider all ICD-9 codes invalid, and require an ABN for the order. If you do not assign a validation set to the insurance company for the selected practice, then the system uses the system default diagnosis validation selection. |
| Internal Billing Status Rules | Select the button to select the appropriate billing status rule and set any ordering location-based exceptions in the Internal Billing Status page. See the Internal Billing Status topic. The system uses this billing status rule when the patient uses this insurance company. You may also assign billing status rules for specific hosts for this insurance company in the Insurance Company Host Codes section of the page (see below). You may define additional billing status rules in the Billing Status Rules page. When rules or exceptions are set, the button text will turn green and italic. See the Billing Status Rules topic. |
| Edit Company Entity IDs | Select to open the Edit Entity IDs pop-up, where you can view and edit the entity IDs for the insurance company. |
| Active | Select the checkbox to enable users to select the insurance company as the primary, secondary, or tertiary company in a patient's insurance set. Clear this checkbox to restrict users from selecting the insurance company. See the Insurance Search topic. In addition, if an insurance company or plan within a patient insurance set is marked as inactive, you will not be able to assign the insurance set to a new order. See the Patient Insurance Sets topic. The system displays or clears the company or plan from the insurance search results list, depending on your settings for the company and/or plan active/inactive filters. See "Searching for an Insurance Company or Insurance Plan" above. |
| Is Validated | Select the checkbox to indicate this company is validated. Insurance company information must be validated to be sent with an order, unless the ability to send non-validated insurance is enabled for the host interface. See the Interface Configuration topic. You may view non-validated companies in the Validate Insurance page. See the Validate Insurance topic. The system displays or clears the company or plan from the insurance search results list, depending on your settings for the company and/or plan validated/non-validated filters. See "Searching for an Insurance Company or Insurance Plan" above. |
| Is Preferred | Select the checkbox to specify that the insurance company is the one that is preferred over others in the system. Preferred companies will appear in bold and filter to the top of the search. |
| Allow Client Bill | Select the checkbox to allow practices or providers to bill the client for testing. If the Allow Client Bill for Medicare for this practice setting is enabled on the Practices page, then that setting supersedes this setting; otherwise, this setting determines if the insurance can be client bill based on any practice, location, or user administration settings. If neither of the allow client bill settings are enabled, the default status will always be direct bill. Note that this option must be enabled in order to use client bill as the default for locations or practices. |
| Use Medicare ABN | Select the checkbox to have the system generate all ABNs for the selected insurance company using the Medicare format; otherwise, the ABNs will use the non-Medicare format. The system automatically updates this checkbox as you modify the Insurance Type field (see below); however, you may manually override the automatic setting by either selecting or clearing the checkbox. The system only applies the 2008 ABN format to Medicare insurance types. It uses the previous format for non-Medicare insurance types. Also, the Preview button on the System Defaults page always uses the new ABN format, no matter what kind of insurance the patient has. |
| Insurance Type | Select the insurance type from the drop-down list (Unknown, Medicare, Medicaid, or Private). The system uses this setting when performing medical necessity checking and determining when to print ABNs. The system determines whether an Advance Beneficiary Notice (ABN) is required based on the selected diagnosis and the patient's insurance, the frequency limits for the order choice, and whether the order choice is set as a research/experimental order choice. In addition, if the setting to fail all diagnosis codes is set for the order choice, then the system always triggers an ABN for that order choice, no matter what the diagnosis code is. Once it determines an ABN is necessary, the system uses the Use Medicare ABN setting (see above) to determine whether to print the Medicare ABN or non-Medicare ABN. |
| Company Order Choice Restriction List | Select Add in this section to add, using the Order Choice List Search page, the order choice lists that you want to make available on the Order Patient Samples page for patients with the selected insurance company. See the Order Choice List Search topic. To delete an order choice list from the list, select X that corresponds to the order choice list name. When you select one or more order choice lists and enable the order choice restriction feature on the Locations page, then users will only be able to select order choices that are on the selected lists when placing orders. The system will use the order choice restriction lists for the insurance plan level, if set, instead of this restriction list; however, it uses this restriction list instead of the one defined for the ordering location's practice, if set. |
| Insurance Company Routing | This section enables you to add or edit the default routing information for the insurance company, as well as assign routing for specific practices or for specific locations. Default Routing: Select the default routing for the insurance company from the drop-down list. The system only displays the routing rules available for the practice associated with your signed-in location. If there is a default insurance routing setting on the System Defaults administration page, then the system selects that routing rule by default. Add Practice: Select the button to assign routing information for a specific practice. From the Practice Search page, search for and select a practice associated with the insurance company. See the Practice Search topic. Repeat this step for each practice that should have specific routing information. Add Location: Select the button to assign routing information for a specific location. From the Location Search page, search for and select a location associated with the insurance company. See the Location Search topic. Repeat this step for each location that should have specific routing information. Routing: Select a routing rule for each practice and location from the drop-down list. Note that if there is a default insurance routing setting in the Practices page for the selected practice, then the system selects that routing rule by default. Also note that location-specific routing takes precedence over practice-specific routing configurations. To delete assigned routing rules, select the blank option from the Routing or Default Routing drop-down lists, and select Save. The system removes the company's default routing or the practice or location name and assigned routing when the page refreshes. The system applies insurance company-based routing rules to determine the testing lab for an order choice when appropriate according to the routing rule hierarchy. See the Order Patient Samples topic. |
| Insurance Company Required Patient Insurance Fields | Use this section to create required fields for insurance information on the Insurance or Insurance Plan pages based on the patient's insurance company. See the Insurance or Insurance Plan topics. These settings override the field requirement settings on the System Defaults and Locations pages. You only need to use this section if the system's default or location settings do not meet the insurance company's information requirements. Show section: Select the link in the section title bar to display the potentially required fields. To hide the fields, select the hide section link that appears in the section title bar. Select an option to determine the required insurance company fields:
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| Insurance Company Host Codes | This section provides the fields to create or modify insurance company host code information. Show section: Select the link in the section title bar to display the host information. The system displays the list of available hosts with their host type and active status. To hide the host information, select the hide section link that appears in the section title bar. Add or edit the host name, type, and active status in the Host Details section of the Hosts details page. See the Hosts topic. Show active hosts only: Select the checkbox to restrict the view to active hosts. Set the active/inactive status in the Host Details section of the Hosts details page. Add Code: Select to add a Host Code, and enter the host code in the Host Code field. To edit the host code, highlight or delete text already displayed in the field, then modify as desired. Internal Billing Status Rules: This button appears if you have added a host code. Select the button to select the appropriate billing status rule and set any ordering location-based exceptions in the Internal Billing Status page. See the Internal Billing Status topic. The system uses the selected billing status rule when the patient uses this insurance company and testing is performed at the selected host. You may define additional billing status rules in the Billing Status Rules page. When rules or exceptions are set, the button text will turn green and italic. See the Billing Status Rules topic. X: Select the X that corresponds to the host code to delete the host code. The system prompts you to confirm the deletion. Select OK to continue. |
| Insurance Plans | This section displays the insurance plans assigned to the insurance company. New Insurance Plan: Select the button to create a new insurance plan. This button is only enabled if your assigned role contains the necessary rights to add new insurance. |
| Back to Search | Select to return to the page of search results you were viewing on the Insurance list page without saving any changes. |
| Save | Select to record changes and return to the Insurance list page. The system alerts you if you attempt to save an insurance company or insurance plan record that contains a duplicate host code. |
| Cancel | Select to return to the Insurance list page without saving any changes. |
Adding and Editing Insurance Plan Information
The Insurance Plan Information section enables you to add or edit insurance plan information and assign plans to a different company, if needed.
| Display page side by side | If there was a plan associated with your selected insurance company, the system displays the Insurance Plan Information section on this page; see "Adding and Editing Insurance Plan Information" below. Select the Display page side by side checkbox to view the insurance company and plan information side by side. Clear the checkbox to view the company information above the plan information. If you choose to view the information side by side, the system displays the Align company and plan sections option. Select the option to have the system space the sections within the company and plan information so that they line up for easier comparison. |
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| Change Log | Select to view the change log for the selected insurance plan. See the Change Log topic. |
| Plan Name | Enter the insurance plan name. This field is required. |
| Plan ID | Enter the insurance plan ID. Note that the system enters the ID for newly created plans. |
| Phone Number | Enter the primary phone number. |
| Contact Last Name | Enter the last name of the insurance plan contact. |
| Contact First Name | Enter the first name of the insurance plan contact. |
| Contact Middle Name | Enter the middle name of the insurance plan contact. |
| Contact Phone Number | Enter the phone number of insurance plan contact. |
| Address Type | Select from the drop-down the type of address for the plan. |
| Address 1/Address 2/ZIP Code/City/State/Country | Enter the full address for the insurance plan, including any suite numbers. If ZIP code checking is enabled in the System Defaults page, then, when you enter a ZIP code that exists in the database, the system automatically fills in the city and state associated with the ZIP code, and if the ZIP code update option is enabled, then the system also updates the corresponding city and state data, if appropriate. |
| Internal Billing Status Rules | Select to select the appropriate billing status rule and set any ordering location-based exceptions in the Internal Billing Status page. See the Internal Billing Status topic. The system uses this billing status rule when the patient uses this insurance plan. You may also assign billing status rules for specific hosts for this insurance plan in the Insurance Plan Host Codes section of the page (see below). You may define additional billing status rules in the Billing Status Rules page. See the Billing Status Rules topic. |
| Active | Select the checkbox to enable users to select the insurance plan as the primary, secondary, or tertiary plan in a patient's insurance set. Clear this checkbox to restrict users from selecting the insurance plan. See the Insurance Search topic. In addition, if an insurance company or plan within a patient insurance set is marked as inactive, you will not be able to assign the insurance set to a new order. See the Patient Insurance Sets topic. If the insurance plan is inactive, the system clears it from the insurance search results list. |
| Is Validated | Select the checkbox to indicate this plan is valid. Insurance plan information must be validated to be sent with an order. You may view nonvalidated companies in the Validate Insurance page. See the Validate Insurance topic. |
| Is Preferred | Select the checkbox to specify that the insurance plan is the one that is preferred over others in the system. Preferred plans will appear in bold and filter to the top of the search. |
| Plan Order Restriction List | Select Add in this section to add, using the Order Choice List Search page, the order choice lists that you want to make available on the Order Patient Samples page for patients with the selected insurance plan. See the Order Choice List Search topic. To delete an order choice list from the list, select the X that corresponds to the order choice list name. Note When you select one or more order choice lists and enable the order choice restriction feature on the Locations page, users will only be able to select order choices that are on the selected lists when placing orders. The system will use the order choice restriction lists for the insurance plan level, if set, instead of the lists defined for the insurance company or the ordering location's practice, if set. |
| Insurance Plan Routing | This section enables you to add or edit the default routing information for the insurance plan, as well as assign insurance plan-based routing rules for specific practices or for specific locations. Default Routing: Select the default routing for the insurance plan from the drop-down list. The system only displays the routing rules available for the practice associated with your signed-in location. If there is a default insurance routing setting in the System Defaults page, the system selects that routing rule by default. Add Practice: To assign routing information for a specific practice, select to search for and select a practice associated with the insurance plan in the Practice Search page. See the Practice Search topic. Repeat this step for each practice that should have specific routing information. Add Location: To assign routing information for a specific location, select to search for and select a location associated with the insurance plan in the Location Search page. See the Location Search topic. Repeat this step for each location that should have specific routing information. Routing: Select a routing rule for each practice and location from the drop-down list. If there is a default insurance routing setting in the Practices page for the selected practice, the system selects that routing rule by default. Also note that location-specific routing takes precedence over practice-specific routing configurations. To delete assigned routing rules, select the blank option from the Routing or Default Routing drop-down list, and select Save. The system removes the plan's previously assigned default routing, or the practice or location name and assigned routing when the page refreshes. The system applies insurance plan-based routing rules to determine the testing lab for an order choice when appropriate according to the routing rule hierarchy. See the Order Patient Samples topic. |
| Insurance Plan Required Patient Insurance Fields | Use this section to create specialized information fields in the Insurance page. You only need to use this section if the system's system default insurance fields do not meet the insurance plan's information requirements. Show section: Select the link in the section title bar to display the potentially required fields. To hide the fields, select the hide section link that appears in the section title bar. Select an option to determine the required insurance plan fields:
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| Insurance Plan Host Codes | This section provides the fields to create or modify insurance plan host code information. Show section: Select the link in the section title bar to display the host information. To hide the host information, select the hide section link that appears in the section title bar. The system displays the list of available hosts with their host type and active status. Add or edit the host name, type, and active status in the Host Details section of the Hosts details page. See the Hosts topic. Show active hosts only: Select the checkbox to view active hosts only. You set the active/inactive status in the Host Details section of the Hosts details page. Add Code: Select to add a host code, then enter the host code for the insurance company in the Host Code field. To edit the host code, highlight or delete text already displayed in the field, then modify as desired. Internal Billing Status: The system displays this button if you have added a host code. Select the button to select the appropriate billing status rule and set any ordering location-based exceptions in the Internal Billing Status page. See the Internal Billing Status topic. The system uses the selected billing status rule when the patient uses this insurance plan and testing is performed at the selected host. You may define additional billing status rules in the Billing Status Rules administration page. See the Billing Status Rules topic. X: To delete the host code, select the X that corresponds to the host code. |
| Harvest LIS Synchronization for this Insurance | This section displays Harvest LIS synchronization information for the selected insurance. The table displays columns for the host's name, version number, active status, selection ability, and a non-sync option. In the Host Name column, the name of the host is displayed; in the Version column, the version is displayed; in the Host is Active column, the active status is displayed; select the Select checkbox in the Select column to select the specific host; and select the Do Not Sync (Sync 2) checkbox to specify that the system should not sync that specific host. Show active hosts only: Select the checkbox to have the system only display active hosts contained within the system. Unsync Selected: Select to unsync selected items in the section. A host must be selected for this button to be enabled. Selecting this button will display the Sync Options pop-up with the two buttons on the pop-up. Select Close to close the pop-up. Sync Selected: Select to sync selected items in the section. A host must be selected for this button to be enabled. Selecting this button will display the Sync Options pop-up with the two buttons on the pop-up. Select Close to close the pop-up. |
| Mapped Practice Specific Insurance Plans | This section is available if you are viewing a system-maintained plan. This section displays the system plan the practice-specific plan is mapped to. |
| Mapped System Plan | This section is available if you are viewing a practice-specific insurance plan. This section displays the practice plan(s) mapped to the system plan. Remove Mapping: Select next to the desired plan to remove a mapping between the selected plans. |
| Assign Plan to different Company | Select this button located at the bottom of the page to search for and select the desired company name in the Insurance Search page. See the Insurance Search topic. Once you select the desired company, the system displays the new insurance company information in the Insurance Company Information section of the Insurance details page. |
| Back to Search | Select to return to the page of search results you were viewing on the Insurance list page without saving any changes. |
| Save | Select to record changes and return to the Insurance list page. The system alerts you if you attempt to save an insurance company or insurance plan record that contains a duplicate host code. |
| Cancel | Select to return to the Insurance list page without saving any changes. |
