Setting Up Insurance Plans

1. Open the Insurance Billing Initial Setup window. For information, go to To open the Insurance Billing Initial Setup window.
2. Select an insurance carrier from the Carrier drop-down menu.

   OR

   Add an insurance carrier. Go to To add and modify insurance carriers for information about adding insurance carriers.

3. Click the Plan tab.

1. Open the Insurance Billing Initial Setup window. For information on opening the Insurance Billing Setup window, see Setting Up Insurance Plans.

2. Select an insurance carrier from the Carrier drop-down menu.

3. Click the Active check box to change the insurance carrier status.

   If the Active check box has a check mark, the insurance is active. If it does not have a check mark, the insurance is inactive.

1. Open the Plan tab on the Insurance Billing Initial Setup window. For 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.

   If you are creating a plan that is similar to one that you have already created, select the existing plan, click Copy to duplicate the plan, and adjust the details as needed. For information on copying insurance plans, go to To copy insurance plans.
3. Type the insurance plan’s name, address, and telephone information in the fields provided.

   OR

   Select the Same as Insurance checkbox to copy the insurance carrier’s address.

   If the insurance carrier is VSP, you must enter a valid VSP address, including all spaces and punctuation.
4. Type the HL7 identifier for the insurance plan in the HL7 ID field as needed.
5. Enter a date in the Activation Date field.
6. Enter a date in the Termination Date field.
   • The activation and termination dates are determined by your contract with the insurance plan and control when products and services can be billed to the insurance carrier.
   • These dates are not required by OfficeMate, which can process claims even when the dates are missing or expired.
7. Select a pricing method from the Pricing Method drop-down menu.
   • Select the pricing method depending on the needs of your practice and how much detail you want to record for each plan. The more detail you enter for each plan, the more streamlined your check-out and billing process will be.
   • Determine which pricing method best suits the needs of your practice.
     • For the most detail, select Detailed Benefits. (See Setting Up Plan Detailed Benefits.)
     • For moderate detail, select Maximum Allotments. (See Setting Up Plan Maximum Allotments.)
     • For the least amount of detail, select Percentage. (See Setting Up Plan Percentages.)
   • Even though the Detailed Benefits and Maximum Allotments pricing methods require more work to set up, you can save time by using the copy feature, which allows you to quickly duplicate plans and adjust details as needed.
     
     If the carrier is VSP, select Percentage from the Pricing Method drop-down menu.
8. Type the main contact information for the insurance carrier in the following fields as needed:
   • Contact
   • Job Title
   • Contact Phone #
   • Contact Email
9. Select Yes from the Create Claim radio buttons to generate claims for this insurance plan. Select No if you do not accept this plan, and the patient is responsible for submitting a claim.
10. Select Yes from the Hold Claim until product is dispensed radio buttons to prevent the claims from being printed or transmitted until the order has been filled. The claim will be available for billing when the Dispensed radio button is selected on the Rx Order window. Select No to print or transmit the claims immediately.
11. Select Yes from the Suppress Claim Edits at Store radio buttons to prevent the claims from being edited at the location level. Select No to allow edits to be made to the claims.
12. Select Carrier, Plan, or None from the Name and Address on Claim form radio buttons to control what address populates the receiver’s portion of the claim.
13. Select the fee that populates box 24F on the CMS 1500 form from the Box 24f Price Charges drop-down menu.
    • If you converted from OfficeMate Enterprise 1.x or OfficeMate 8.x or below to 9.x or above, the default selection for the Box 24f Price Charges drop-down menu is Product Fee; if your products and services do not have fees assigned to them, then $0.00 appears in box 24F on the CMS 1500 form.
    • If you selected No from the Secondary Claim Recipient, remaining charges only radio button in To add and modify insurance carriers and you select to populate the Feeslip Fee in box 24F, then the transferred items’ fee is displayed on the CMS 1500 form. If you selected No from the Secondary Claim Recipient, remaining charges only radio button in To add and modify insurance carriers and you select to populate the Product Fee in box 24F, then the original charges billed on the fee slip are displayed on the CMS 1500 form.
14. Select Yes from the Include non-covered items on Claim radio buttons to include items that are not covered under the plan on the claim form. Select No to prevent items that are not covered from appearing on the claim.
15. Type the place of service code in the Box 24b Place of Service field.

    To view a complete list of place of service codes, go to the CMS website.

16. Select provider or facility from the Box 31 Source drop-down menu according to the plans requirements for box 31.
17. Select Location or Corp. from the Box 32 Print Address radio buttons to print either the location’s address or the home office’s address.
18. Select Yes from the Box 33 Print Corporate Address radio buttons to print the home office’s address on the claim. Select No to suppress the home office’s address.
19. From the Box 33 Billing Entity drop-down menu, select the biller information that should appear in box 33 on the CMS 1500.
20. In the Enter the number of Claim copies to print field, type the number of copies of the claim form to print.
21. Type the information provided by your electronic claims company or clearinghouse in the following fields as needed:
    • Destination ID
    • Payor ID
    • Payor Sub ID
    • If you are entering a destination ID for NSF files, type the destination ID provided by your electronic claims company or clearinghouse or type 000.
    • If the insurance carrier is VSP, type 000 in the Destination ID text box.
    • If you are processing insurance claims through McKesson, type the CPID in the Payor ID text box.
22. Click Save to save your changes.

For more information, watch this video.

1. Open the Plan tab on the Insurance Billing Initial Setup window. For 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, go to To add & modify insurance plans.

3. Click the Preferences tab.
   If the carrier is VSP, ensure that all Discounts and Eligibility and Combining Attributes radio buttons are set to No.
4. Select Yes from the Prevent Discount on Fee Slip radio buttons to prevent discounts over and above any discounting that is part of this insurance plan that could cut into your margin. Select No to allow additional discounts.
5. Select Yes from the Eligibility Required radio buttons if an eligibility number is required for this plan. Select No if eligibility is not required.
6. Select Yes from the Authorization Required radio buttons to require patients’ authorization ID on the Eligibility window. After you set up this preference, you must ensure that patients using this insurance plan have their authorization ID recorded on the Carrier window. Select No if authorization is not required.
7. For each of the pairs of radio buttons in the Combining Attributes group, select Yes or No.
   • Selecting the Yes radio button combines two or more items with the same CPT code onto one line on the insurance claim. The quantity on the claim reflects the number of items, and the charges on the claim reflects the sum of the charges for the individual items.
   • Selecting the No radio button lists each item as a separated line item on the insurance claim.
8. Select Yes from the Split Frame radio buttons to split the frame cost to two lines on the CMS 1500. Select No to list frames as a single line item on the CMS 1500 and go to step 10.
   When the frame cost is split, the first line is entered on the CMS 1500 with a V2020 code. Any amount above the price point you select in step 9 is split onto the second line with another code, usually V2025.
9. If you selected to split the frame cost in step 8, type the price point at which the frame is split in the Split @ field and select a billing code from the CPT/HCPCS drop-down menu.
10. Select the frame and contact pricing range that appears on the CMS 1500 from the Pricing Range radio buttons.
11. In the Exam Elig. Period spin box, type the number of months in which the plan states the patient may return.
12. From the Recall Type drop-down menu, select the recall type for the plan.
13. Select Yes from the Transfer Co-Pay to Secondary Insurance radio buttons if the plan allows a secondary insurance to pay the copay. Select No if the copay cannot be transferred to a secondary insurance.
14. Select Yes from the Secondary Recipient, accept Co-Pay transfer radio buttons if the insurance plan pays the copay when it is secondary. Select No if the plan does not pay the copay.

1. Open the Plan tab on the Insurance Billing Initial Setup window. For information on opening the Plan tab, 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, go to To add & modify insurance plans.

3. Click the Dispensing Fees tab.
4. Click New to create a new dispensing fee.

   OR

   Select an existing dispensing fee from the list to edit a dispensing fee.

   OR

   Select an existing dispensing fee from the list and click Copy to duplicate a dispensing fee.

5. Select a product type from the list.
6. Select a billing code from the Code drop-down menu.
7. Type the fee in the Fee field.
8. Click Save to save your changes.
9. Repeat steps 4–8 for each dispensing fee you want to add to this insurance plan.
10. Select Yes from the Display Dispensing Fees on Patient’s Fee Slip/Statements radio buttons to include the dispensing fees on fee slips and statements. Select No to suppress the dispensing fees on the fee slips and statements.
11. Click Save on the Plan tab to save your changes.

1. Open the Plan tab on the Insurance Billing Initial Setup window. For 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, go to To add & modify insurance plans.

3. Click the Notes tab.
4. Click New Note to add a timestamp.

   Today’s date and your name are inserted at the top the notes text box.

5. Type your notes in the space provided.
6. Click Save when you are finished.
7. Click Print Notes to print the notes as needed.
   For information on attaching eDocuments (e.g., insurance contracts, plan descriptions), go to Attaching Electronic Documents to Insurance Carriers & Plans.

The Insurance at a Glance window is informational only. Information entered in the glance window does not affect insurance billing. Insurance billing information does not affect the information entered on the Glance window.The Glance window provides free-form information as a summary of the plan details. Opticians may refer to the insurance glance information on the Insurance tab on the Patient Demographic window while assisting patients.

1. Open the Plan tab on the Insurance Billing Initial Setup window. For 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. Click Glance.

   The Insurance at a Glance window opens.

4. Type information in the text boxes as needed.
5. If you have an electronic or scanned copy of the insurance plan information, perform the following steps:
   1. Save the file to a folder within the OfficeMate folder on the network so the file is accessible to everyone.
   2. Type the path to the file in the Document Path field.
6. Click Save when you are finished.
7. Click Print to print the glance information as needed.
8. Click Preview to view the print preview of the glance information as needed.

   The Preview window opens and displays the glance information in a format suitable for printing. If you attached an electronic document in step 5, that document will open after the Preview window.

9. Click Exit to close the Insurance at a Glance window.

1. Open the Plan tab on the Insurance Billing Initial Setup window. For information, go to To open the insurance Plan tab.
2. Click Copy.

   The Copy Plan window opens.

3. Select an insurance carrier from the Select Carrier drop-down menu.
4. Select a plan from the results list.
5. Select the check boxes that correspond to the information you want to copy into the new insurance carrier.

   If the insurance plan that you selected in step 4 uses the detailed benefits pricing method, and if you select the Pricing method check box from the Copy Plan options, the Copy Pricing Method options will appear. The Copy Pricing Method options allow you to specify the product categories the you want to copy to the new insurance.

6. Select the check boxes that correspond to the pricing methods that you want to copy into the new insurance carrier, if the Copy Pricing Method options are available.
7. Click OK.
8. Modify the insurance plan as needed. For information, go to To add & modify insurance plans.