Configure Capitation and Capitated Plans

Capitation payments are not like other income. How should you configure PCC EHR in order to track payments you receive as part of your participation with a capitation insurance plan?

Read the steps below to learn how to create appropriate insurance groups, plans, and income accounts to record and track capitation policies and payments.

Contact PCC Support: PCC Support will complete the steps in this article for you, but you may find the instructions helpful if you are a system administrator or practice manager and make updates to your PCC tables.

For this example, you will create a new capitated insurance company, “INSCO Insurance” and configure it so you can post capitation payments to it.

Contents

1 Create the Insurance Groups, Plans, Fees, Payment Types, and Accounts to Record and Track Payments
2 Post Capitation Payments

Create the Insurance Groups, Plans, Fees, Payment Types, and Accounts to Record and Track Payments

In order to track payments, first create a number of items in PCC’s underlying tables.

Create Two New Insurance Groups
1. Open the Tables tool from the Configuration menu.
2. Open the “Insurance Groups” table
3. Add Two New Insurance Groups:
  - INSCO Insurance
  - INSCO Insurance Cap Clearing
4. Edit “Reporting Position” field with sequential order numbers. This will help the two groups appear together on various practice management reports.
Create New Insurance Plans
1. Open the “Insurance Plans” table
2. Add a new insurance: “INSCO Insurance Cap Clearing”. Make sure it uses the INSCO Insurance Cap Clearing group. This plan will be used to track payments.
3. Add each new capitated plan with assistance from PCC Support’s billing specialists. These plans will appear as policies on patient accounts.
Create Capitation Fee and Payment
1. Open the “Procedures” table
2. Add a new procedure called “Capitated Fee”.
  - Give it an accounting type of Revenue – Non-service
  - Add it to the appropriate group for reporting purposes. You might consider creating a new procedure group to track capitation income.
3. Open the “Payment Types” table
4. Add a new payment type called “Capitation Check Payment”
  - Give it a type of “Check”
  - Allow it to be posted through personal and insurance payment posting.
Add a New Account and Patient For Tracking Payments
1. Create a new patient record. First name: INSCO Insurance, Last name: Cap Clearing.
2. Add the insurance “INSCO Insurance Cap Clearing” to the patient’s policies.
3. Create a new account record. First name: INSCO Insurance, Last name: Cap Clearing.
4. Link the new patient to the new account.

Post Capitation Payments

In order to not deflate your A/R with a credit, you will post the Capitation Check adjustment procedure at the same time as you post the Capitation Check payment. The incoming check will pay off the adjustment procedure, creating no change in your A/R.

To learn how, read Post Capitation Checks, Incentive Payments, Interest Payments, Overpayments, and Withhold Payments, or watch the tutorial video.

Here are some related articles in Billing and Practice Management > Bill Insurance:

Post Less-Common Payments
Learn how to record capitation payments, incentive payment, insurance interest payments, withhold payments, and overpayments in PCC EHR.
Post Capitation Checks, Incentive Payments, Interest Payments, Overpayments, and Withhold Payments
Learn how to record capitation checks, incentive payments, insurance interest payments, payment amounts that exceed the amount due on a charge ("Overpayments"), and end-of-year withhold payments
Read EDI Responses to Claim Submissions
Your practices receives many different electronic responses to claim submissions and billing. Read this article to learn the different EDI responses, which responses require attention, and how to use PCC's tools to review and respond.
Submit Claims
Use the Claims tool to process and submit claims to insurance companies and other payers, work on claims that could not be submitted, and review a log of submissions.
Insurance Billing Overview
PCC's insurance billing tools help you process and prepare claims, send them electronically or print them, review rejections and denials, fix problems and resubmit, and work down your insurance accounts receivable. You can maximize the use of your time as you pursue proper insurance reimbursement.
Review Archived EDI Reports
After you submit claims, your practice will receive clearinghouse and payor acknowledgements as well as ERAs and other electronic notifications from PCC, claim clearinghouses, and payors. You can use tools in PCC EHR to review these responses. When you need to do deeper research, you can use the EDI Reports (ecsreports) program.
Print Paper HCFA Claim Forms
While most claims are transmitted to payors electronically, sometimes you may need to generate paper 1500 HCFA forms, or print a single paper claim.
The Claim Journey Explained
How is a claim created, and what happens in the background to make sure your practice is paid? Read below to learn some of the "under the hood" workings of claims after you post charges into PCC EHR.
Edit the Insurance Plans On Your PCC System
Use the Tables tool in the Configuration menu in PCC EHR to update the list of plans that your practice bills.
Add an Attachment Code to a Claim
If a secondary insurance requires the EOB from the primary, or any claim requires a certificate of medical necessity, discharge summary, or other clinical documentation, you need to send an attachment to the payor. You can edit the encounter and add an attachment code to an encounter, generate a unique attachment ID, and specify the attachment type and method. Attachment information will then be sent with the electronic claim.
Edit the Insurance Plans on Your PCC System
Use the Tables tool in PCC EHR to add a new insurance plan and configure the payors you send claims to.
Submit Claims
Prepare and submit claims. Then work on any claims that were stuck and couldn't be submitted.
Configure Claim Holds and Claim Delay
Watch this video to learn how to hold claims for specific providers, locations, or plans and how to configure your practice's claim delay.
Configure Claim Holds and Claim Delay
When your practice needs to prevent certain claims from being submitted, you can create a claim hold. A claim hold prevents claims from going out for specific dates of service, billing providers, places of service, and insurance plans. You can also configure your practice’s claim delay, which prevents any claim from going out until a certain number of days after the date of service.
Account Notes and Encounter Billing Notes
Learn how to enter and review account notes and encounter billing notes in PCC EHR.
Work on Claim Errors and Rejections
After you prepare and submit claims, you must deal with claims that could not be submitted or were rejected.
Claim Processing and Needs Correction Error Reference
What kinds of pre-submission processing does your PCC system do on claims? What errors can it find, and how do you fix them?

Create the Insurance Groups, Plans, Fees, Payment Types, and Accounts to Record and Track Payments

Post Capitation Payments

Related Articles