Understanding Insurance Schedule Methods and Method Components

An insurance schedule method is a specific benefit for a specific item type and is composed of various method components. Examples of method components include Discount Type and Allowance Type. The calculation types you select for a method’s components determine how the method functions when you apply the insurance plan to a patient’s order in AcuityLogic POS. Although each method may have multiple method components, you may not be required to select an amount for each component.

This section describes the methods that you can apply to item types when you are creating an insurance schedule.

Topics include the following:

Insurance Schedule Methods
Insurance Schedule Method Components

Insurance Schedule Methods

This table lists the following:

All the methods that you can apply to item types when creating insurance schedules. Not all methods are available for each insurance plan.
All the components available for each method. For details, see Insurance Schedule Method Components.
All the item types to which each method can be applied. Not all methods are available for each item type. A method you set up for an item type applies only to that item type, not to any other products or services.

Method Name	Use This Method When . . .	Method Components	Item Types With This Method
Accessory Discount	The plan offers a discount toward accessories.	Discount Type	Special Option
Allow -> Discount - Contract	The plan requires that you apply the allowance and then apply a discount to the retail price of an item. This is based on the contractual discount indicated, and it is not eligible for any additional sales or promotional discounts.	Allowance Type Receivable Type Copay Type Discount Type	Frames
Allow -> Discount - Highest	The plan requires that you apply the allowance and then apply a discount. Typically the plan specifies what the discount is, but the plan could indicate that a sale or promotional discount can be applied if that discount is higher than the contractual discount. When you use this method, the highest discount is calculated.	Allowance Type Receivable Type Copay Type Discount Type	Frames
Allow -> No Discount	The plan has an allowance but does not allow any other discounts to be applied.	Allowance Type Receivable Type Copay Type	Frames
Allowance/Exam (Deduct Exam Pay)	The plan calculates the final allowance by subtracting the contact lens exam and routine exam receivables from the contact lens allowance. For example, if the patient’s allowance is $100 and the total exam receivable is $75, the final allowance is $25.	Allowance Type Receivable Type Copay Type Discount Type	Contact Lens
Allowance/Exam (Deduct Exam Retail)	The plan calculates the final allowance by subtracting the total retail price of the contact lens exam and the routine exam from the contact lens allowance. For example, if the patient’s allowance is $100 and the total retail price of the patient’s exams are $80, the final allowance is $20.	Allowance Type Receivable Type Copay Type Discount Type	Contact Lens
Allowance Item	The plan offers an allowance for the item type. The allowance can cover a full item type, or only a specific dollar amount or percentage of an item type. You can specify a copay and a discount as well. Sometimes the same result can be achieved by using this method or the Discount Item method. The difference is how the write-off is indicated on reports. On reports, this method indicates that a write-off is a contractual write-off, while the Discount Item method indicates that a write-off is a discount.	Allowance Type Receivable Type Copay Type Discount Type	Exams Material Addon Style Addon Color/Coat Addon Tint Edging Coating Misc. Extras Contact Lens Misc Fees
Allow Eyeglass Lens Material Based on Rx	The plan allows premium lens materials (such as polycarbonate or high-index plastic) at no added cost when the combined Rx power from either eye meets a minimum value. Combined Rx Power equals the sum of the Sphere and Cylinder values.	Allowance Type Receivable Type Allowed Material / Item Name OR Allowed Item Group Minimum Combined Rx Power Optional Note (Displayed during order pricing) Optional Note (Displayed during order pricing when selected material is not included in the order)	Special Option
Allow Office Additional Discount	This method is currently in development and has no functionality.	N/A	Special Option
Allow Package Discount	The plan allows you to apply a package discount and then apply an allowance on the remaining balance.	N/A	Special Option
Allow Photochromic for Minor	The plan allows a minor to purchase eyeglasses with photochromic lenses.	Receivable Type Minor Age Limit	Special Option
Allow Polycarbonate by Age	Polycarbonate lenses are fully covered by the plan when the patient’s age and relationship to subscriber satisfy the set criteria.	Receivable Type Minor Age Limit Polycarbonate Covered Up to Age Patient's Relationship to Subscriber	Special Option
Allow Safety Frames	The plan offers an allowance for safety frames.	Allowance Type Receivable Type Copay Type Discount Type	Special Option
Allow Transitions for Minor	The plan allows a minor to purchase eyeglasses with Transitions lenses.	Receivable Type Minor Age Limit	Special Option
Apply Medicaid Copay Reduction For Same Day Service	A Medicaid plan waives the copay for an exam when it is sold with eyewear.	N/A	Special Option
Benefit By CPT Code	The plan (usually a Medicaid plan) offers benefits based on the CPT code of the lens base type.	Copay Type Copay Code Type	Lens Base Type
CL Allowance -> Fitting	The plan applies the allowance to contact lenses first, and then applies any remaining balance of the allowance to the contact lens fitting.	Allowance Type Receivable Type Copay Type Discount Type Contact Lens Required	Contact Lens
Covered Item/No Receivable	The plan offers an allowance for an item type but does not reimburse the provider for that item type. For example, a material upgrade for glass is often allowed in full but not reimbursed.	Allowance Type	Material Addon Style Addon Color/Coat Addon Tint Edging Coating Misc. Extras Misc Fees
Discount -> Allow - Contract	The plan requires that you apply a discount to the retail price of an item and then apply the allowance. This is based on the contractual discount indicated and the item is not eligible for additional sales or promotional discounts.	Allowance Type Receivable Type Copay Type Discount Type	Frames Style Addon
Discount/Allow Entire Lens	The plan offers a discount and an allowance on the entire lens.	Allowance Type Receivable Type Copay Type Discount Type	Material Addon Style Addon
Discount -> Allow - Highest	The plan requires that you apply a discount to the retail price of an item and then apply the allowance. Typically the plan specifies what the discount is, but the plan could indicate that a sale or promotional discount can be applied if that discount is higher than the contractual discount. When you use this method, the highest discount is calculated.	Allowance Type Receivable Type Copay Type Discount Type	Frames
Discount -> Base Allowance	The plan offers a discount on the base lens.	Allowance Type Receivable Type Copay Type Discount Type	Exams Lens Base Type Contact Lens
Discount Entire Lens	The plan offers a discount on the entire lens.	Discount Type	Material Addon
Discount Item	The plan requires that an item be discounted. Sometimes the same result can be achieved by using this method or the Allowance Item method. The difference is how the write-off is indicated on reports. On reports, this method indicates that a write-off is a discount, while the Allowance Item method indicates that a write-off is a contractual write-off.	Discount Type Maximum Retail Limit	Frames Exams Lens Base Type Material Addon Style Addon Color/Coat Addon Tint Edging Coating Misc. Extras Contact Lens Misc Fees
Discounted Retail Before Allowance	The plan first applies a discount and then applies the allowance.	Allowance Type Receivable Type Copay Type Discount Type Discounted Retail	Frames Exams Lens Base Type Material Addon Style Addon Color/Coat Addon Tint Edging Contact Lens
Dispensing Codes and Rule Setup	The plan has dispensing fees. After this rule is set up and dispensing fees are created as products in AcuityLogic, dispensing fees are added to patient orders when you apply the insurance plan to an order. Depending on which option you select for the Dispensing Rule attribute, the dispensing fees either replace all the items on the order or are added to the order. You must fill in all the fields for the dispensing codes. If you are not using one of the dispensing codes, you can copy another dispensing code into that code’s field.	Dispensing Rule SV Dispensing Code BF Dispensing Code TF Dispensing Code PG Dispensing Code Frame Only Order Type Dispensing Code Lenses Only Order Type Dispensing Code	Special Option
Dispensing Item	This method is currently in development and has no functionality.	Allowance Type Receivable Type Copay Type Discount Type Charge Back Amount	Frames Exams Lens Base Type Material Addon Style Addon Color/Coat Addon Tint Edging Coating Contact Lens
Display Contact Lens Message	The message you type appears in a dialog box when you apply the insurance plan to an order when pricing contact lenses in AcuityLogic POS.	Message	Special Option
Display EyeGlass Message	The message you type appears in a dialog box when you apply the insurance plan to an order when pricing eyeglasses in AcuityLogic POS.	Eye Glass Message	Special Option
Display Generic Message	The message you type appears in a dialog box when you apply the insurance plan to an order when pricing any item in AcuityLogic POS.	Message	Special Option
EyeMed Annual Plan Limit	The EyeMed plan specifies the following: An annual allowance limit A coinsurance payment based on a percentage of your receivable amount for an item, not the retail price for the item. When setting up the items in the insurance schedule, set the allowance to retail and the receivable to your EyeMed contracted reimbursement rate for the item. Set the Copay to percent of receivable and enter the coinsurance percentage for the plan.	Receivable Limit Limit Type	Special Option
Find Previous CL Fitting Fees	The plan allows you to search for previous contact lens fitting fees.	N/A	Special Option
Fitting -> CL Allowance	The plan applies the allowance to a contact lens fitting first and then applies any remaining balance of the allowance to contact lenses.	Allowance Type Receivable Type Copay Type Discount Type Contact Lens Required	Contact Lens
Frame Overage Rule	The plan (usually Spectera) issues a charge-back when a patient purchases a pair of frames whose price exceeds the allowance offered by the plan.	% Charge Back Fee	Special Option
Frame Wholesale Allowance	The plan requires that you apply the allowance to the frame based on the wholesale cost of the frame. You can apply additional discounts after the allowance.	Allowance Type Receivable Type Copay Type Discount Type Extra % Patient Pays Of Diff Extra % Patient Pays Of Wholesale	Frames
Frame Wholesale Discount	The plan requires that you discount the frame based on the wholesale cost of the frame.	Discount Type % Covered of Allowance Extra % Patient Pays Of Diff Extra % Patient Pays Of Wholesale	Frames
Lens/Allowance	The plan specifies an allowance for the base lens (SV, BF, TF). Some plans may also have an allowance for progressives. Lenses are considered plastic unless otherwise specified.	Allowance Type Receivable Type Copay Type Discount Type	Lens Base Type
Lens/Frames Allowance	The plan specifies an allowance for frame and lenses when both are purchased together.	Allowance Type Receivable Type Copay Type Discount Type	Lens Base Type
Material Allowance	The plan offers a total allowance for materials (such as contact lenses and frames) but does not offer an allowance for exams.	Allowance Type Receivable Type Copay Type Discount Type Discount Rule Include Fitting Fee Material Type Valid Allowance Include Eyeglass Extras	Special Option
Material/Lens Combined Allowance	The plan specifies a combined allowance for materials and lenses.	Allowance Type Receivable Type Copay Type Discount Type	Material Addon Style Addon
Material Copay	The plan offers one copay for all materials (although the copay may exclude contact lenses).	Copay Type Material Type	Special Option
Maximum Allowance Limit	The plan specifies a maximum allowance for specific item types.	Allowance Limit Limit Type	Special Option
Medicaid Frames	The plan offers a special allowance or discount for Medicaid frames.	Allowance Type Receivable Type Copay Type Discount Type	Special Option
Medicaid Modifier Rule	The plan requires special modifiers for Medicaid eyeglass replacements and prescription changes.	Is this a Covered Replacement Frame? Modifier When Replacement Frame is Yes or No Is this a Covered Replacement Lens? Modifier When Replacement Lens is Yes or No Is this Lens a Qualifying Prescription Change? Modifier for Qualifying Lens Rx	Special Option
No Copay For Minor	The plan specifies that patients who are a certain age or younger do not have a copay for specific product or service types.	Service Type Minor Age Limit	Special Option
No Discount On License Frame	The plan does not allow discounts on licensed frames.	N/A	Special Option
No Exam Copay for High Prescriptions	The plan specifies that a patient does not have an exam copay when his or her prescription is over a certain diopter power. For example, the plan specifies that patients don’t pay copays when their prescription is over +/- 8.00.	Prescription Over	Special Option
Not Allowed	The plan does not allow the order to be processed when a patient attempts to purchase a specific item. The patient must select another item.	N/A	All Item Types (may not always be available for Special Option)
Not Covered Charge Back Rule	The plan charges a charge-back for noncovered lenses and lens options. This method functions only when the Not Covered Item Discount (Lens & Options) method is also applied to the plan. This example explains how your charge-back and net sale are calculated using the Not Covered Charge Back Rule. An example noncovered coating retails for $100. The insurance plan gives a 20% discount ($20) to patients for noncovered coatings, so the patient pays $80. The insurance plan then charges you a 10% charge-back ($8), so your net sale on this coating is $72 ($100-$20-$8).	% Charge Back Fee	Special Option
Not Covered Item Discount (Lens & Options)	The plan does not offer any benefits for lenses but allows you to apply a discount to the item.	Discount Type	Special Option
Not Covered with Total/Material Allowance	The plan requires that the specified item group or item be excluded from Material Allowance or Total Allowance special option calculations.	N/A	Coating Color/Coat Addon Edging Lens Base Type Material Addon Misc. Extras Style Addon Tint
Override Base Lens Discount	The plan allows you to override the benefits calculation for a base lens with the discount set up for a style addon.	Discount Type	Style Addon
Override Lens Base Allowance	The plan allows you to override the price of a base lens if the patient upgrades to a premium lens so that the patient is charged for the premium lens.	Discount Rule Allowance Type Receivable Type Copay Type Discount Type	Style Addon
Plano Lenses Not Allowed	The plan does not allow plano lenses.	Note (displayed during order pricing)	Special Option
Senior Citizen Discount Rule	The plan offers a discount to senior citizens.	Senior Citizen Age Discount Type	Special Option
Special Program	The plan offers a special program for the item type.	Allowance Type Receivable Type Copay Type Discount Type Special Program Name	Frames Exams Lens Base Type Material Addon Style Addon Color/Coat Addon Coating Contact Lens
Spectera CL Fit without Contacts	The plan provides coverage towards a contact lens fitting fee without a contact lens purchase if the fit is for a Spectera formulary contact lens. You can use this method to set up Spectera insurance schedules so that AcuityLogic POS users are prompted when insurance is applied to an order that includes a contact lens fitting fee without a contact lens purchase. If users indicate that the fitting fee is for a formulary contact lens, the system includes the allowance, receivable, and copay amounts set up in its benefits calculations. If users indicate that the fitting fee is not for a formulary contact lens, the system does not apply coverage for the service.	Allowance Type Receivable Type Copay Type	Exams
Spectera Contact Lens Only	The Spectera plan offers specific allowances for the fitting fee for formulary (covered) contact lenses.	Covered Fitting Fees Covered CL Type Allowance Type Copay Type	Contact Lens
Spectera Contact Lens Receivable	The Spectera plan offers specific allowances on contact lenses. Enter receivable percentages for either allowance or retail.	Receivable Cap for Covered Disposable (Per Box) Receivable Cap for Covered Planned Replacement (Per Box) Formulary Receivable Percentage of allowance Formulary Receivable Percentage of Retail	Special Option
Spectera Non Formulary Contact Lens Only	The Spectera plan offers specific allowances on nonformulary (not covered) contact lenses.	Allowance Type Non Formulary Receivable Percentage	Contact Lens
Sunglasses or Sportvision Discount	The plan offers a discount for sunglasses or eyewear for sports.	Discount Type	Special Option
Total Allowance	The plan offers a total allowance toward everything, including exams and materials.	Allowance Type Receivable Type Copay Type Discount Type Discount Rule Valid Allowance Allowance Limit	Special Option
Total Allowance Includes Exam and Contact Lens	The plan offers a total allowance toward exams and contact lenses only.	Allowance Type Receivable Type Copay Type Discount Type Allowance Limit	Contact Lens
Total Allowance Includes Exam, CL, & Fit	The plan offers a total allowance toward exams, contact lenses, and contact lens fittings only.	Allowance Type Receivable Type Copay Type Discount Type Allowance Limit	Contact Lens
Total Allowance with only Base Lens	The plan offers an allowance for base lenses and does not cover upgrades to premium products.	Allowance Type Receivable Type Copay Type Discount Rule Discount Type Valid Allowance Allowance Limit Shared Allowance Amount Copay Rules	Special Option
Valid Labs Rule	The plan requires that orders are made at specific labs.	Valid Lab	Special Option
VSP Plan Requirements	The VSP plan requires that lenses are made at specific labs.	VSP Lab Rule VSP Network Schedule	Special Option

Insurance Schedule Method Components

This table describes all the method components and calculation types that you can apply to methods when creating insurance schedules.

Not all components are available for each method. Although each method may have multiple components, you may not be required to select an amount for each component. Record an amount only for the method components applicable to the insurance plan’s requirements.

All method components and calculation types you set up for a method apply only to the item type that the method is for, not to any other products or services. See Insurance Schedule Methods.

Method Component	Calculation Types
% Charge Back Fee	The percentage of the item’s price that you pay to the insurance carrier as the charge-back fee.
% Covered of Allowance	Leave this attribute blank. It has no functionality.
Allowance Limit	The patient’s maximum allowance.
Allowance Type	None: The patient does not have an allowance. Retail: The allowance covers the full retail amount. Enter: Enter the dollar amount of the allowance. % of Retail: The allowance is a percentage of the retail price. Enter the percentage. Call: When you process an order and click Calculate Benefits, a dialog box appears and asks you for more information. % of Entered Amount: The allowance is a percentage of the entered amount. Enter the percentage. % of Call Amount: The allowance is a percentage of the call amount. Enter the percentage.
Base Lens	The base lens to which the method applies.
BF Dispensing Code	Type the dispensing code for bifocal lenses.
Charge Back Amount	The dollar amount of the charge-back.
Contact Lens Required	Yes: The patient must purchase contact lenses to receive the allowance. No: The patient does not have to purchase contact lenses to receive the allowance.
Copay Type	None: The patient does not have a copay. Enter: Type the dollar amount of the copay. Call: The copay is unknown until eligibility is checked, or the copay varies between patients. When you process an order and click Calculate Benefits, a dialog box appears and asks you for more information. % of Allowance: The copay is a percentage of the allowance. Enter the percentage. % of Receivable: The copay is a percentage of the receivable. Enter the percentage.
Covered CL Type	Disposable: The allowance applies to disposable contact lenses. Non Disposable: The method applies to nondisposable contact lenses.
Covered Fitting Fees	The maximum dollar amount of fitting fees that the plan covers.
Discount Rule	No Discount: No discount applies. Discount Before Allowance: Apply a discount to the retail price of an item, and then apply the allowance. Discount After Allowance: Apply the allowance to the retail price of an item, and then apply the discount.
Discount Type	None: No discount applies. Discount %: Type the percentage of the discount. Discount amount: Type the dollar amount of the discount. Charge Amount: Type the dollar amount that is to be charged. Do not select this option if you set up the Allowance Type and Receivable Type attributes. Call for Charge Amount: A specific amount must be charged, but the amount is unknown until eligibility is checked, or the amount varies between patients. When you process an order and click Calculate Benefits, a dialog box appears and asks you for more information. Do not select this option if you set up the Allowance Type and Receivable Type attributes. Call for Discount %: The discount varies between patients or needs to be entered manually. When you process an order and click Calculate Benefits, a dialog box appears and asks you for more information. Multi Level Discount $: The dollar amount of the discount depends on the price level of the item. For example, an item type that retails for $100-$150 may receive one discount while the same item type that retails for $151-$200 may receive another discount. For each level, type the maximum retail price in the Discount Level fields, and type the dollar amount of the discount in the Retail Limit fields. Multi Level Discount %: The percentage of the discount depends on the price level of the item. For example, an item type that retails for $100-$150 may receive one discount, while the same item type that retails for $151-$200 may receive another discount. For each level, type the maximum retail price in the Discount Level fields, and type the percentage of the discount in the Retail Limit fields. Multi Level Mix: The plan offers both a dollar and a percentage discount. Set the discount up like the Multi Level Discount $ and Multi Level Discount % discounts described in the preceding items.
Discounted Retail	The maximum total retail dollar amount to which the discount applies. For example, if the plan offers a 15% discount and you set the discounted retail to $100 but the patient purchases a $200 item, the discount applies only to the first $100 of the purchase, so the total discount is $15.
Dispensing Rule	Replace all invoice items with Dispensing Code: AcuityLogic replaces all invoice items, including exam fees and professional fees, with a dispensing code. If you use this rule and want to invoice an exam or professional fee on the same invoice, create an Exam Only plan, and bill the fee to the Exam Only plan. Append Dispensing Code to invoice items: AcuityLogic adds the dispensing code to the invoice items.
Extra % Patient Pays Of Diff	Leave this attribute blank. It has no functionality.
Extra % Patient Pays Of Wholesale	Leave this attribute blank. It has no functionality.
Eye Glass Message	Type the message to display in a dialog box when you apply the insurance plan to an order when pricing eyeglasses in AcuityLogic POS.
Frame Only Order Type Dispensing Code	Type the dispensing code for frame-only orders.
Include Eyeglass Extras	Yes: The material allowance for the plan applies to edgings, tints, and miscellaneous eyeglass lens extras. No: The material allowance for the plan does not apply to edgings, tints, and miscellaneous eyeglass lens extras. The material allowance applies to coatings whether you select Yes or No. If you do not want the material allowance to apply to coatings, set up the Total Allowance and Not Covered with Total/Material Allowance special option methods for the Coating item type.
Include Fitting Fee	Yes: The plan offers an allowance for fitting fees. No: The plan does not offer an allowance for fitting fees.
Lenses Only Order Type Dispensing Code	Type the dispensing code for lenses-only orders.
Limit Type	Complete Order With Exam: The allowance applies only to a complete order with an exam. Eg Order Only: The allowance applies only to eyeglasses. Frame And Base Lens Only: The allowance applies only to frames with a base lens. Lens And Extra Only: The allowance applies only to lenses and extras. Frame Only: The allowance applies only to frames. Lenses Only: The allowance applies only to lenses. Extra Only: The allowance applies only to extras. Exam Only: The allowance applies only to exams.
Material Type	Lens & Frame: The allowance covers lenses and frames. Lens, Frame, & Contacts: The allowance covers lenses, frames, and contact lenses. Contacts Only: The allowance covers only contact lenses. Frame: The allowance covers only frames. Lenses Only: The allowance covers only lenses.
Maximum Retail Limit	The maximum total retail dollar amount to which the discount applies. For example, if the plan offers a 15% discount and you set the maximum retail limit to $100 but the patient purchases a $200 item, the discount applies only to the first $100 of the purchase, so the total discount is $15.
Message (Display Contact Lens Message)	Type the message to display in a dialog box when you apply the insurance plan to an order when pricing contact lenses in AcuityLogic POS.
Message (Display Generic Message)	Type the message to display in a dialog box when you apply the insurance plan to an order when pricing any item in AcuityLogic POS.
Minor Age Limit	Type the maximum age of a patient who is eligible for the method.
Prescription Over	Type the starting diopter power for which the exam copay is waived. For example, if you type 8.00, a patient with a prescription over +/- 8.00 has no exam copay.
PG Dispensing Code	Type the dispensing code for progressive lenses.
Receivable for Covered Disposable (Per Box)	Type the receivable for each box of covered disposable contact lenses.
Receivable for Covered Planned Replacement (Per Box)	Type the receivable for each box of covered planned replacement contact lenses.
Receivable Type	None: No compensation. Enter: Type the dollar amount for the contract or fee specified by the plan. Allowance: The receivable is equal to the amount of the allowance recorded for the Allowance Type attribute. % of Allowance: The contract or fee schedule is a percentage of the allowance. Enter the percentage. Call: When you process an order and click Calculate Benefits, a dialog box appears and asks you for more information.
Senior Citizen Age	Type the minimum age of a patient who is eligible for the method.
Service Type	Lens & Frame: The patient does not have a copay when purchasing lenses or frames. Lens, Frame & CL: The patient does not have a copay when purchasing lenses, frames, or contact lenses. Lens, Frame, CL & Exam: The patient does not have a copay when purchasing lenses, frames, contact lenses, or an exam. ExamOnly: The patient does not have a copay for exams. FrameOnly: The patient does not have a copay for frames. CLOnly: The patient does not have a copay for contact lenses. LensFrameExam: The patient does not have a copay when purchasing lenses, frames, and an exam.
Special Program Name	Type the name of the special program.
TF Dispensing Code	Type the dispensing code for trifocal lenses.
SV Dispensing Code	Type the dispensing code for single-vision lenses.
Valid Allowance	Leave this attribute blank. It has no functionality.
VSP Lab Rule	Only Allow VSP Contract Labs: Lenses can be made only at VSP contract labs. Only Allow Private Labs: Lenses can be made only at private labs. Only Allow Charity VSP Labs: Lenses can be made only at charity VSP labs. Allow All Lab Choices: Lenses can be made at any lab.
VSP Network Schedule	The VSP network schedule to which the lab rule applies.

Understanding Insurance Schedule Methods and Method Components

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