Adding and Modifying Insurance Plans

  • For multitenant environments, the following setup can be performed only by administrators of the parent company and is required only for the parent company. The parent company setup applies to all companies.
  • You must fill out all fields marked with an asterisk (*).

To add and modify insurance plans

  1. Open the Insurance Plan window. See Opening the Insurance Plan Window.
  2. Perform a search if necessary. See Searching for Insurance Plans.
  3. Do one of the following:
    • To create an insurance plan, click Create New.

    • To modify an existing insurance plan, click the plan's name in the Plan Name column.

    • If you want to add multiple plan schedules to multiple offices at the same time, click Add Plans to Offices. See Assigning Offices to Insurance Schedules for more information.

    The fields for creating or modifying the insurance plan appear.

  4. Select the Active check box to mark the plan as active. Inactive plans do not appear in search results and cannot be added to patients.
  5. Select the carrier name from the Carrier Name drop-down list.
  6. Enter the plan name in the Plan Name field.
  7. If you send claims for the insurance plan through the VSP interface, enter the plan code in the Plan Code field.
  8. Select one of the following plan types from the Plan Type drop-down list:
    • Benefit: A plan for which you give a specified benefit to a patient, and the insurance company pays you a contracted fee for that benefit.
    • Discount: A plan for which you give a specified discount to a patient, but you are not reimbursed by the insurance company.
    • Medicaid: Any Medicaid plan, regardless of the insurance carrier.
    • Safety: Any plan that gives benefits only for safety glasses. Selecting Safety enables you to bill claims for the plan through the Statement Forms module in AcuityLogic Billing.
  9. Select the coverage type from the Coverage Type drop-down list.

    If you select Vision Only, a warning appears in AcuityLogic POS when you select a medical diagnosis.

    If you select Medical Only, a warning appears in AcuityLogic POS when you select a refractive diagnosis.

  10. Enter or select the plan start date in the Start Date field.
  11. Enter or select the plan review date in the Review Date field if necessary. You may want to review plan details, such as contract fees, before your contract is up for renewal so that you can evaluate whether to continue with the plan.
  12. Enter or select the plan termination date in the Termination Date field.
    The termination date is determined by your contract with the insurance carrier and controls when products and services can be billed to the insurance carrier.
  13. Select a subscriber type from the Allowed Subscriber drop-down list.
  14. Select the benefit frequency from the Recycle Period field. The recycle period determines whether the patient is eligible for the plan’s benefits once every 12 months or once every 24 months.

    For a list of VSP plan codes, see Modifying Insurance Plan Information for the VSP Interface.

  15. If you bill claims for the plan through TriZetto and the plan’s EDI payer ID is different from the insurance plan’s payer ID, type the EDI payer ID in the EDI Payer ID field.

    A payer ID recorded in this field overrides the payer ID assigned to the insurance carrier.

  16. Leave the Purchase Order field blank. This area is currently undergoing development and offers no functionality at this time.
  17. If the insurance plan requires that office location information be included on the claim form, select the Office Location Required check box.
  18. Select the VSP Plan Bill Procedures check box if you submit claims for medical procedures for VSP.
  19. If the insurance plan requires that provider information be included on the claim form, select the Provider Required check box.
  20. Select the Manual check box if the fee schedule items vary by patient and cannot be set up for the entire plan in the insurance schedule.
    If you select the Manual check box and then price an order in AcuityLogic POS, click the Calculate Benefits button. This displays the Manual Calculation box so that you can manually record the copay, total patient responsibility, and insurance reimbursement.
  21. If the plan is an unknown plan and users need to enter the carrier contact information for the plan manually when adding it to a patient's profile, select the Not Listed check box.
  22. To override the insurance carrier rules:
    1. Select the Override Carrier Rule check box.
    2. Select an eligibility option for the plan from the Eligibility drop-down list.

      • Eligibility and Authorization: You must record eligibility and authorization information for each transaction.

      • Eligibility: You must record eligibility information for each transaction.

    3. Select an authorization number format from the Number Format drop-down list if necessary.

      The As, 9s, and dashes in each format represent the letters, digits, and dashes that the authorization number must comprise. For example:

      • A-999999999 (A1-N7): The format is one letter, a dash, and seven digits.
      • 9999 (N4): The format is four digits.
    4. Select a billing method from the Billing Mode drop-down list.
    5. Select an insurance ID format from the Insurance ID Format drop-down list if necessary.
  23. Select which entity is responsible for paying tax on the insurance receivable or allowance from the Taxes Responsibility drop-down list (previously called the Taxes Portion list). Select any of the following options:
    • Patient (previously “Customer”)
    • Carrier
    • Company
    The entity you select is charged the tax amount that you select from the Taxable Charge Amount drop-down list. See step 23.
  24. From the Taxable Charge Amount drop-down list, select one of these options to specify how the entity selected from the Taxes Responsibility list is charged:
    • None: The entity is not charged additional taxes.
    • Reimbursement less Copay: (Default) The entity pays taxes on the reimbursement minus the copay.
    • Reimbursement including Copay: The entity pays taxes on the reimbursement plus the copay.
    • Contractual Allowance: The entity pays taxes on the contractual allowance.
  25. To charge taxes on patient copays, select the Charge Tax on Copay to Patient check box.
    • This check box is enabled only if you selected Patient from the Taxes Responsibility list and you selected Reimbursement less Copay from the Taxable Charge Amount list.
    • If you select the Charge Tax on Copay to Patient check box when setting up your office, AcuityLogic charges tax on all copays, regardless of the setting in the insurance plan.
  26. To override the insurance carrier address, select the Override Insurance Carrier’s Address Fields check box, and enter the insurance plan’s address and contact information in the appropriate fields in the Address Fields box.
  27. To override carrier information for the CMS 1500 form:
    1. Select the Override Carrier’s HCFA Settings check box.
    2. From the Billing Charge Amount drop-down list, select how the charge amount is calculated for box 24F on the CMS 1500 form.
    3. Select an insured ID type from the Insured ID drop-down list. The selected ID type appears in box 1a on the CMS 1500 form.
    4. Select a group health type from the Group Health Type drop-down list. If the carrier is not Medicare or Medicaid, select Group Health. The selection appears in box 1 on the CMS 1500 form.
    5. Select an option for using Rx modifiers for the power of lenses from the Rx Modifier drop-down list. The Rx modifiers appear in box 24D on the CMS 1500 form.
      • Use Rx Modifier: Use the specific CPT power for the selected lens.
      • Do not use Rx Modifier: Use the first CPT code in the series (for example, SV - 2100) instead of the specific code for the power.
      • Use maximum Rx Modifier: Use the higher CPT code.
    6. If the right and left eye codes are identical, select the Combine Lens Base check box to combine them in one line item with a quantity of 2. If you do not select this check box, the right and left eye codes are always in two different line items. The line items are listed in section 24 on the CMS 1500 form, and the quantity is displayed in box 24G.
      You can select the Combine Lens Base check box only if the Split Lens Components check box is deselected.
    7. If the carrier is a Medicare DME carrier, select the Split Lens Components check box to automatically split the charge amounts, receivables, and copays for lens components (including lens base, coating, style, color, tint, edging, and miscellaneous extras) and for contact lenses. When you select this check box, AcuityLogic splits the items into two single (Qty=1) line items—one with the RT modifier and one with the LT modifier—in Medicare DME claims.

      • You can select the Split Lens Components check box only if the Combine Lens Base check box is deselected.

      • To be a Medicare DME carrier, the Medicare DMERC check box must be selected.

      • You must add RT and LT modifiers to your billing rules for items previously billed as pairs. See Setting Up Insurance Billing Rules.

    8. Select an NPI option from the Service Location NPI (CMS Box 32a) drop-down list. The service location NPI appears in box 32a on the CMS 1500 form.
    9. Select a billing NPI option from the Billing Provider NPI (CMS Box 33a) drop-down list. The billing provider NPI appears in box 33a on the CMS 1500 form.
    10. Select a place of service from the Place of Service drop-down list. The place of service appears in box 24B on the CMS 1500 form.
    11. Select the Bill Non-Covered Items check box to submit all line items on the CMS 1500 form, regardless of whether you receive a receivable from the insurance company for those items.
    12. Select one or both Billing based on material delivery options:
      • Put claims on hold until delivered: When this option is selected, claims created for orders are put on hold until the status for the orders is set to Delivered in POS. At that time, their claim status is changed to Ready to Bill. (If the patient has primary and secondary insurance, this rule applies only to the primary insurance.)
      • Switch service date to delivery date: When this option is selected, the service date is replaced by the delivery date throughout the claim in Billing, such as in the Service Date field at the top of the Claim Detail page and in the Date of Service fields in section 24 of the Edit Claim page.
      • You can select both options or only the first option. You cannot select only the second option.
      • If you select only the first option, the delivery date does not replace the service date in the claim.
      • In the Claim Detail window in Billing, new Claim History notes are automatically added for any status and service/delivery date changes made by this feature.
      • This feature does not apply to exam-only orders.
      If you turn this feature off by deselecting Put claims on hold until delivered, AcuityLogic does not automatically change all On Hold claims to Ready to Bill. Instead, you must manually review your On Hold claims—for example, by searching for Claim Status = On Hold in Billing's Claim Management tab or by running the On Hold Claim Report (GB112)—and change only qualified claims to Ready to Bill.
  28. Click Save to save your changes.

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