The Insurance Plan Tables

This article is a reference to the Insurance Companies table and the Insurance Groups table, both of which are in the Table Editor (ted). They contain information about the insurance policies on your PCC system, which are used for billing and reporting.

Watch a Video to Learn About Insurance Tables: You can watch an overview your system’s insurance tables in the Update Patient Insurance Policies: Billing Office video.

Introduction: What is an Insurance Table?

You can add a new policy to a patient’s record quickly and easily with the Policies component in PCC EHR. (The functionality is mirrored in PCC’s Partner billing system.)


However, when you add a new policy, what master list of insurance plans do you search from?

Your practice has a custom list of the insurance plans that you bill. That list is kept in the Insurance Companies table in the Table Editor (ted).

Insurance Companies

The Insurance Companies table has a separate entry for every policy on your system, with multiple policy listings for different copay agreements.

Insurance Table Columns

Here are the columns and what each one indicates:

Column Label:Description:
INSURANCE PLAN NAMEFull name of the insurance company plan/carrier
ADDRESSAddress of the plan, useful for differentiating plans with the same name
PNDDo charges pend this insurance company by default?
MEDIs this a MEDICAID type plan?
CAPIs this plan CAPITATED by default?

When adding a plan, you can either type A to add a new plan from scratch or type C to clone an existing insurance plan as discussed in the Quickstart section above. Even if you plan to make major changes, PCC recommends you use the “Clone” feature. This will ensure that every required field is filled out.

Insurance Plan Fields

Whether you are adding, cloning, or simply reviewing an insurance plan, you will see a screen with details about the plan. Fill in each field as described here and press Enter to move from field to field.

 

Insurance Group

Individual plans are grouped together for Practice Management Reports. You can use the asterisk (*) in this field and include this plan in an already existing insurance group. (See the information on ted to learn how to add new insurance groups).

Plan Name

The name of the insurance plan. Always include the default copay amount in the plan name so it can be easily differentiated. Some offices also include the PO Box used for claim submission to ensure the correct plan is always selected.

Short Name

An abbreviated name for the insurance plan. It is used when displaying the plan name in various place in Partner.

Address

The mailing address that will appear on paper claims.

HCFA BatchThe batch that controls claim grouping and formatting for this plan. Individual plans are grouped in these batches for the purpose of generating similar claims. You can use the asterisk (*) to see a list of existing claim batches. Plans with the same batch generally share provider ID#s and other options controlled in the Configuration Editor (ced). The HCFA batch that claims are grouped into has no connection to the Insurance Group field.

All Insurance Plans Need a Batch: This field should never be empty. It controls the formatting of your claims for this payer. If you believe you need to add a new batch for some reason, contact PCC and a Customer Care technician will assist you.

Group Claims By:

This field was originally used for controlling active plans. It is no longer needed and can be ignored.

Eligibility ID, Ins Type, Filing ID, Subs Filing ID, Aux Payor ID

These fields are used in special circumstances for claim submission. They were added due to HIPAA changes to claim submission formats. You can ignore these fields unless directed by PCC. Do not change the text in these fields.

Payer IDThe identification number used for electronic claim submissions to this plan. Insurance plans from the same company generally share the same Payer ID number.

Where Do I Find an Insurance Plan's Payer or Payor ID?: If you cloned an existing insurance plan of the same company, the payer ID number may already be correct. Otherwise, the ID might appear on the insurance card. Otherwise, there may be a phone number on the card for claims that you can call to determine the correct payer ID. You can also talk to PCC Support for help tracking down the ID.

Special Information FileThe system path to the insurance plan’s ibar file. Insurance plans use these files as a filter for all procedures. The file defines whether or not each procedure should pend, HCFA, or capitate. It can also define special copay situations.

All Insurance Plans Need a Special Information File: This field should never be empty, as it determines charge and claim-level behaviors. If you have cloned a similar insurance company, then this field is probably filled out appropriately already. Otherwise, you can use the asterisk (*) to see a list of ibar files on your system.

Is this a Medicaid plan?

A Yes/No question that determines whether this plan will behave like a medicaid plan. If set to “Yes,” then:

  • The plan will always be sorted below non-Medicaid insurance policies when a patient has multiple coverage. (Medicaid will be secondary or tertiary, it will not be primary when the patient has other coverage.)
  • Charges pending the plan will appear with an asterisk (*) in the Correct Mistakes (oops) program.
  • You can post payments in the Post Insurance Payments (pip) program, as you would for any insurance policy. You will also be able to post payments in spam, a special “Medicaid-only” payment posting program, which automatically adjusts off the unpaid amount of claim.
  • PCC Dashboards will consider that plan, and any other plans in the same insurance group, to be Medicaid-type plans for reporting purposes.

Is this a capitated plan?

A Yes/No question that sets the default capitation behavior for this plan. If set to “Yes,” charges posted to this plan will be adjusted off at the time of service. Keep in mind that the Special Information File can overrule this question and configure adjustment behavior for all procedures.

Default copayment

The expected copay amount for this plan. You should enter this information in the name of the plan as well as here, so that selecting the plan will be easy for your staff. Keep in mind that the Special Information File can overrule how much copay to charge for each procedure.

If your new plan has different copay amounts for different types of procedures, put the most common or default copay in this box. The Special Information File can be configured to automatically set the copay for each procedure. Read the ibar section below for more information.

Accept Assignment

A Yes/No question that turns pending for this plan on and off. If this plan does not accept assignment, then charges posted to it will remain the personal responsibility of the guarantor and will not generate claims. Keep in mind that the Special Information File may override this setting and force charges to pend to the insurance company.

Copay Questions

A series of Yes/No questions that determine copay behavior for this insurance plan. If there is no copay then you don’t need to bother with these questions. Otherwise, use them to define how and when the copay is expected. The first should almost always be set to yes, as it assigns a copay for a visit to the doctor’s office. The second question defines whether a copay should be charged for hospital visits. The final question sets one copay for every procedure. Keep in mind that the Special Information File can also control and affect what copay is charged and for which procedures.

Insurance Notes: If you want to enter any specific notes relating to this plan you can press F8Change Notes. The notes you add will be visible in the Policies component in PCC EHR, the Patient Insurance Policies screen in Partner, and will appear when you post charges for a patient with this insurance plan.

After you make changes to an insurance plan, press F1Save and Quit or press Page Down or Page Up to save your work.

Insurance Groups

The Insurance Groups table lists groups used for reporting purposes. All Insurance Companies (policies) have an assigned Insurance Group.

Insurance Groups have a name, an order number (used for determining how they appear in reports), and a “Tot?” signifier, indicating whether or not charges and payments for policies in each group should be included in reporting totals.

  • Last modified: July 3, 2018