Edit the Insurance Plans On Your PCC System

The plan’s name and short name indicate how the plan will appear on lists and in a patient’s policy record. Practices typically include the expected default copay amount in the plan name, making it easier to select the correct plan when adding a patient’s policy.

Your practice maintains a custom list of Insurance Groups in the Insurance Groups table. Groups are used for financial reporting and do not affect claims or billing behaviors for procedures.

These details for a plan are typically found on the back of an insurance card. They are sometimes used for claim submission and to followup on claims.

The default expected copay for this plan. You should enter this information in the name of the plan as well, so that selecting the plan will be easy for your staff. A plan’s rules file can override what copay to charge for each procedure.

If a plan charges different copays for different procedures, put the default copay in this field.

A series of Yes/No questions that determine default copay behavior for this insurance plan.

• Copay Office POS: Is a copay typically expected for a visit to the office?

• Copay Hospital POS: Is a copay typically expected for a hospital visit?

• Copay Hospital POS: Is a copay charged for each charged procedure?

Use these questions to define default copay expectations. When handling an encounter’s charges, your PCC system checks these questions and then refers to the rules file, which can override these question and define more precise copay expectations.

The set of configuration rules that will be used to generate a claim. When charges are posted for an encounter and a claim is queued up, it is labeled as being part of a particular “batch” and will be processed in a specific way to meet the requirements of a payor. Plans are assigned a batch so claims will be submitted in adherence with those requirements.

A plan’s batch for claims is not connected to the plan’s insurance group, which is used for reporting, but the values may match or be similar. For example, your practice may have a reporting group for Medicaid plans as well as a special batch for handling the configuration of medicaid claims.

All Insurance Plans Need a Batch: This field normally shouldn’t be empty. It controls the formatting of your claims for the payer. If you believe you need to add a new batch, contact PCC.

A configuration file that can be used to implement special per-procedure behaviors, overriding the default needs for the insurance plan.

When you post charges, PCC checks the rules in this file, also known as the “Special Information File”. The rules set whether procedures should pend the insurance plan at all, appear on claims, capitate, use a special price schedule (rare, as insurance contracts generally disallow this), or write off an amount or percentage of the procedure’s price. Additionally, the rules can define what copay should be charged for each procedure, overriding the Copay Amount for the plan.

If you believe you need to create a new set of rules to meet the unusual billing requirements of a payer, contact PCC. For most situations, select the “standard” rules.

If this value is set to no, charges posted to this plan will (by default) remain the personal responsibility of the billing account for the patient. The rules file can override this behavior and determine precisely which procedures will pend to the plan.

On claims, this value communicates to the payor whether or not payment should be directed to the practice or the patient. If set to no, the payment should be directed to the patient. If set to yes, the provider has a participation agreement with the payer and the payment should be directed to the practice. Your practice’s insurance configuration for this plan’s batch can override how this value appears on claims.

A Yes/No question that determines whether this plan will follow certain medicaid behaviors by default. If set to “Yes,” then:

• The plan will always be sorted below non-Medicaid insurance policies when a patient has multiple policy coverage. (If a patient has more than one insurance policy, Medicaid policies will be secondary or tertiary, etc.) If this plan ever needs to be the primary plan in front of a private insurance, you should not set the Medicaid question to “Yes”.
• The policy will be marked with an “M” for easy reference. For example, nurses may need to grab immunizations from a different location for patients with a Medicaid-type plan. Wherever insurance policies are listed, an “M” icon will appear making it easy for them to identify that the patient has Medicaid.
• Some reports, such as those found in your Practice Vitals Dashboard, will consider the plan, and any other plans in the same insurance group, to be Medicaid-type plans for reporting purposes.

A Yes/No question that sets the default capitation behavior for this plan. If set to yes, then charges posted to this plan will be adjusted off at the time of service. However, the Rules File can override this question and configure the specific desired adjustment behavior for procedures. PCC Support will help set up and configure adjustment behaviors for capitation plans.

The contract fee schedule used for this payer. If your practice enters your contract fee schedules into PCC, you can automatically review claim responses that fail to meet the schedule and report on overpayments and underpayments over time. For more information, see Use Contract Fee Schedules (Allowables) to Monitor Reimbursement.

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

Where Do I Find an Insurance Plan's Payer ID or Payor ID?: If you cloned an existing insurance plan of the same company, the ID number may already be correct. Otherwise, the payor’s ID should appear on the insurance card, or you can call the number on the card. The carrier is required to provide an ID number for claim submission.

An identification number or alpha-numeric code used for requesting eligibility information for a patient. These are standardized for a given payor, so are usually easy to find on the internet. If you are unable to find an eligibility identification number, contact the payor.

An identifier used for specific situations, such as a secondary medicaid claim submission in which the primary payor required a proprietary identifier (a “Carrier Code”).

A parent category for the type of claim submission used for the plan. Most commercial plans are “Commercial Insurance Co.” or “CI”. Medicaid and BCBS have unique claim filing indicators.