Insurance Plans
Every payer and plan this client bills. A patient’s coverage points at one of these, and a claim inherits the payer, the filing indicator and the filing limit from it.
Who Can See It
Section titled “Who Can See It”User only, when the client is licensed for insurance plans.
The List
Section titled “The List”| Column | What it shows |
|---|---|
| Name | The plan as billers refer to it |
| Payer ID | The identifier the payer is addressed by on an 837 |
| Payer Type | The program the payer runs: Medicare, Medicaid, Commercial, BCBS, TRICARE, CHAMPVA, Workers’ Comp, Self-Pay or Other. Analytics can break a report down by it. CMS-1500 box 1 is ticked from the claim’s filing indicator, not from this |
| Location | The city and state of the plan’s own address |
| Filing Limit | Days from service before the payer stops accepting the claim. As the secondary payer, days from the primary payer’s decision, except for Medicare. No limit set when it is 0 |
| Submission | How the payer takes claims: Electronic or Paper |
| Phone | Who to call |
Filing Limit is what drives the deadline countdown on a claim, so a wrong value here shows up as a wrong deadline on every claim billed to the plan.
Above the list, Total counts the plans and Payers the distinct payer IDs. Search matches the plan name or payer ID.
Actions
Section titled “Actions”| Action | What it does | When it is offered |
|---|---|---|
| Create | Adds a plan | Always |
| Edit | Changes one | From the row menu, or by selecting the row |
| View History | Opens Insurance Plan History: who changed the plan and what they changed | From the row menu |
| Delete | Removes one. A plan that any patient coverage uses, even an ended one, is refused | From the row menu |
Editing a plan does not revisit claims already built from it.
On a new plan, Payer Type follows the Claim Filing Indicator you pick until you choose a payer type yourself; left blank, it is derived from the indicator. When editing, it is required.
| Field | |
|---|---|
| Filing Limit (days) | Days from the earliest date of service to file the payer’s claims. A new plan starts at 365 for Medicare, Medicaid, TRICARE and CHAMPVA and 90 for others, following the payer type until you type a value. 0 leaves the deadline unchecked |
| Follow-up Interval (days) | Days until a claim follow-up comes back after Awaiting Payer, from 1 to 365. Empty uses 14 |
| Appeal Window (days) | Days from a denial to appeal it with this payer, from 1 to 730. Empty uses 120 |
| Portal URL | The payer’s web portal, starting with http:// or https:// |
Changing a plan’s Payer ID carries its providers’ payer enrollments to the new ID, unless another plan still uses the old one.
If someone else saved the plan or payer group after you opened Edit, your save is refused with a notice above the form, and Reload refills it with their version (A Save Was Refused).
The form’s Submission Method offers Electronic (837P) or Paper (CMS-1500) and decides whether the plan’s claims are exported or printed. A paper plan needs its mailing address, because that is what prints in the form’s carrier block; saving one without an address is refused. CMS-1500 Template shows whenever the client is licensed for claims: it offers Use Default with the default’s name, or one of the practice’s templates. A claim copies the method when it is generated, and a draft can override it for one claim.
Switch on Capitated for a plan that pays the practice per member rather than per visit. Its zero-pay remittances that carry CO-24 then post without a review item and settle the claim. On any other plan a CO-24 is still held as Covered by Capitation.
Payer Groups
Section titled “Payer Groups”A payer group is a name you put over several plans so reporting can talk about them together - every Medicaid plan as one line, or a network billed under one contract. Payer Groups in the sidebar lists them, with a Name and when it was Created, and offers Create, Edit, View History and Delete.
A plan belongs to at most one group, set when the plan is created or edited. Grouping changes nothing about how a claim is billed: it only gives Analytics a coarser axis, where Payer Scorecard and Collections Statement can break down by Payer group instead of by individual plan.
States
Section titled “States”- Empty - a client with no plans says so. Claims cannot be billed until one exists.
- Blocked - without the insurance plans module the screen is not in the sidebar, and a saved link to it says the module is not part of your plan.
Related: Patients · The Claim Page · Analytics