Setting Up Plan Maximum Allotments

The maximum allotment pricing method allows you to set up the maximum insurance plan benefits for individual attributes and combinations of attributes.

  • The Maximum Allotments pricing method is only available to practices that upgraded from OfficeMate Enterprise 2.0 or OfficeMate 9.0, 9.5, or 10.0, and had at least one insurance plan that used either the Detailed Benefits or Maximum Allotments pricing methods.
  • If your practice requires a more complex insurance plan setup, go to Setting Up Plan Detailed Benefits. If your practice requires a less complex insurance plan setup, go to Setting Up Plan Percentages.

This section explains how to set up maximum allotments, including how

  1. Open the Plan tab on the Insurance Billing Initial Setup window. For more information, go to To open the insurance Plan tab.
  2. Select an insurance plan from the Select Plan drop-down menu.

    OR

    Click New to add a plan. For information on adding plans, go to To add & modify insurance plans.

  3. Select Maximum Allotments from the Pricing Method drop-down menu.
  4. Click Maximum Allotments.

    The Maximum Allotments window opens.

  1. Open the Maximum Allotments window. For more information, go to To open the Maximum Allotments window.
  2. Click New to add a product or combination of products to the maximum allotments list.

    OR

    Select a product or combination of products from the list to modify it.

    If you are creating a set of maximum allotments that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy maximum allotments.
  3. Select a product type from the Product Type list.
    Select more than one product type from the list to create a combination. For example, many insurance plans have a different pricing structure for frames and ophthalmic lenses when purchased together than when purchased separately.
  4. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
  5. Select one of the % Discounts radio buttons:
    • Select Before if the insurance plan mandates that a discount be applied before the patient’s payment and type the amount of the discount as a percent.
    • Select After if the insurance plan mandates that a discount be applied after the patient’s payment and type the amount of the discount as a percent.
  6. Select None if the insurance plan does not mandate a discount.
    • Select one of the Patient Allotments radio buttons:
    • Select Percent if the insurance plan entitles the patient to a benefit in the form of a percent and type the amount of the allotment as a percent. Type the maximum dollar amount covered in the Max $ Value field.
    • Select Amt if the insurance plan entitles the patient to a specific amount and type the amount of the allotment as a dollar amount.
    Any amount above the patient’s allotment, will be applied to the patient’s out-of-pocket costs.
  7. If there is a limit to the quantity of this product type, enter the quantity in the Limit field.
  8. Select one of the Co-Pay radio buttons:
    • Select Percent if the patient’s copay is a percentage and type the amount of the copayment as a percent and type the maximum dollar amount in the Max $ field.
    • Select Amt if the patient’s copayment is a specific amount and type the amount of the copayment as a dollar amount.
    • Select None if the patient does not have a copay.
  9. Select one of the T/P Reimbursement radio buttons:
    • Select Percent if the insurance plan covers a percent of the patient allotment and type the amount covered as a percent. Type the maximum dollar amount covered in the Max $ Value field.
    • Select Amt if the insurance plan covers a specific amount of the patient allotment and type the amount covered as a dollar amount.
  10. Select one of the Balance radio buttons:
    • Select Write-Off to write off the balance that is not covered by the insurance plan and for which the patient is not responsible.
    • Select Secondary -> W/O to bill a secondary insurance for the uncovered balance.
  11. Click Save to save your changes.
  12. Repeat steps 2–11 to add additional maximum allotment settings.
  13. Close the window when you are finished adding maximum allotments.
  1. Open the Maximum Allotments window. For more information, go to To open the Maximum Allotments window.
  2. Click Copy.

    The Copy Maximum Allotment window opens.

    A confirmation may appear asking you if you want to overwrite any existing maximum allotments in this insurance plan. Select one of the following options:

    - Click Yes to erase all of the plan’s maximum allotments and replace them with those you are about to copy.

    - Click No to keep the current maximum allotments and not copy maximum allotments from another plan.
  3. Select an insurance carrier from the Select Carrier drop-down menu.

    All plans under that carrier with a maximum allotment pricing method appear in the results list.

  4. Select a plan from the list.
  5. Click OK.
  6. Modify the maximum allotments as needed. For information on modifying maximum allotment information, go to To add & modify maximum allotments.