Insurance Policy 3rd

1. Introduction

This document provides a detailed step-by-step guide for configuring and managing insurance policies in GOT2, a comprehensive insurance policy management software. The system allows administrators to set up insurance companies, networks, plans, pricelists, and patient authorizations to streamline claim processing and billing.

2. Insurance Policy Configuration

2.1 Setting Up Overage Amount in Insurance Company

To enable overage calculations:

  1. Navigate to Insurance > Configuration > Insurance Companies.
  2. Select or create an insurance company.
  3. Locate the "Overage Amount" field and enter 2025 (or the applicable amount).
  4. Enable the "Allow Overage" boolean to activate overage calculations.
  5. Save the record.

Note: Overage will only apply if the boolean is set to True.

2.2 Configuring Insurance Network

To define network-specific pricing rules:

  1. Go to Insurance > Configuration > Insurance Networks.
  2. Select or create an insurance network.
  3. Enable the "Is Procode Pricelist" boolean to allow procedure-based pricing.
  4. Save the record.

Impact:

  • When an insurance plan is created under this network, predefined tags will auto-generate for computations.

2.3 Setting Up Insurance Plan with Tags

Insurance plans determine coverage rules. Follow these steps:

  1. Navigate to Insurance > Configuration > Insurance Plans.
  2. Create a new plan or select an existing one.

  3. Ensure the plan is linked to the correct Insurance Network.

    The system will auto-generate the following tags (if enabled in the network):

    • Individual Deductible
    • Family Deductible
    • Individual Max Out of Pocket
    • Family Max Out of Pocket
    • Co-Insurance
    • Group Co-Pay

    • Frame Allowance

      Admin Control:

    • Each tag has a boolean field.
    • If disabled (False), users cannot modify the value.
    • If enabled (True), users can input values.
  4. Fill in the required values for each enabled tag.
  5. Save and validate the record.

2.4 Configuring Procedure Code Pricelist

To define pricing for medical procedures:

  1. Go to Insurance > Configuration > Pricelists.
  2. Select the pricelist linked to the insurance network.
  3. For each procedure code, set the applicable price.
  4. Save the pricelist.

Note: This pricelist will be used for billing calculations when processing claims.

3. Patient Insurance Setup

3.1 Adding Insurance to a Patient

To assign an insurance policy to a patient:

  1. Navigate to Patients > Select or Create a Patient.
  2. Go to the "Insurance" tab.
  3. Click "Add Insurance".
  4. Select the Insurance Company and the applicable Insurance Plan.
  5. Fill in additional required details (policy number, group ID, etc.).
  6. Save the record.

3.2 Creating an Authorization

Authorizations determine coverage limits for a patient.

  1. Inside the patient’s insurance record, click "Add Authorization".
  2. The system will display the same tags as defined in the Insurance Plan.
  3. Update the values for each tag as needed (subject to admin-enabled fields).
  4. Save the authorization.

Key Points:

  • Authorization values cannot exceed the plan limits.
  • The system tracks "Met" values (amount already paid towards a tag).

  • The remaining payable amount is calculated as:

    Remaining Amount = Tag Limit – Met Amount

4. Processing Sales Orders with Insurance

4.1 Applying Insurance in a Sale Order

To bill services using insurance:

  1. Create a new Sale Order (or open an existing one).
  2. Select the patient with an active insurance policy.

  3. Choose the Insurance Company and Authorization from dropdowns.

    The system will:

    • Fetch the applicable pricelist based on the insurance network.
    • Apply coverage rules (deductibles, co-pays, etc.).
    • Calculate patient responsibility based on remaining limits.
  4. Complete the order and proceed with billing.

5. Validations & Business Rules

  • Overage Calculation: Only applies if "Allow Overage" is enabled in the insurance company.

  • Procedure Pricing: Must be defined in the pricelist; otherwise, default pricing applies.

    Authorization Limits:

    • "Met" value cannot exceed the tag’s total limit.
    • If "Met = Limit", no further claims are allowed under that tag.

Insurance Policy Calculation Logic

1. Deductible Calculations

Individual Deductible

Remaining Individual Deductible = Total Individual Deductible - Amount Already Met

Family Deductible

Remaining Family Deductible = Total Family Deductible - Amount Already Met

Applicable Deductible

  • If only Individual Deductible exists:

    Deductible Amount = Remaining Individual Deductible

  • If only Family Deductible exists:

    Deductible Amount = Remaining Family Deductible

  • If both exist:

    Deductible Amount = MIN(Remaining Individual Deductible, Remaining Family Deductible)

2. Out-of-Pocket Maximums

Individual Max OOP

Remaining Individual OOP = Total Individual OOP Limit - Amount Already Met

Family Max OOP

Remaining Family OOP = Total Family OOP Limit - Amount Already Met

Applicable OOP Limit

Max Deductible Amount = MIN(Remaining Individual OOP, Remaining Family OOP)

3. Co-Pay Calculation

Co-Pay Amount = MIN(Remaining Individual OOP, Remaining Family OOP, Plan Co-Pay Amount)

4. Co-Insurance Calculation

Per Line Item

Patient Co-Insurance Responsibility = (Insurance Covered Amount × Co-Insurance %)

Insurance Payment = Insurance Covered Amount - Patient Co-Insurance Responsibility

Cumulative Rule

  • Co-insurance applies only until the patient reaches their OOP max.
  • Once Total Co-Insurance Paid ≥ Max Deductible Amount , insurance covers 100% of remaining costs.

5. Frame Allowance Logic

Covered Amount

Insurance Payment = MIN(Frame Allowance, Frame Retail Price)

Overage (Non-Covered Amount)

  • If Frame Retail Price > Frame Allowance :

    Patient Pays = (Frame Retail Price - Frame Allowance) - Any Frame Discount

6. Patient Responsibility Summary

  1. Co-Insurance Phase
    • Patient pays Co-Insurance %  of each service until OOP max is reached.
  2. OOP Max Reached
    • Insurance pays 100% of covered services
  3. Non-Covered Services
    • Patient pays full amount (e.g., V2025 overage for frames).

7. Example Scenario

Variables:

  • Individual Deductible: 500(200 already met → $300 remaining)
  • Co-Insurance: 20%
  • Individual OOP Max: 2,000(500 already met → $1,500 remaining)
  • Service Cost: $1,000 (Insurance covers full amount per plan)

Calculations:

  1. Deductible Phase:
    • Patient pays $300 (remaining deductible).
    • Remaining service cost: 1,000−300 = $700.
  2. Co-Insurance Phase:
    • Patient pays 20% of 700=140.
    • Insurance pays 80% of 700=560.
    • OP Check:
    • Total patient paid: 300(deductible)+140 (co-insurance) = $440.
    • Remaining OOP buffer: 1,500−440 = $1,060.

Result:

  • Insurance Payment: $560
  • Patient Payment: $440
  • Next Service: Co-insurance continues until patient reaches $1,500 total payments.

This logic ensures accurate cost-sharing between patients and insurers while adhering to plan-specific rules

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