Important: For the automated insurance claim eligibility and billing rules to function, the Insurance company must be selected prior to entering the invoice line item screen .
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The insurance company and policy assigned to each button will be used to create up to four claims based on the invoiced item for the selected invoice. The Primary Insurance is the first to be billed and any payments received by this insurance claim will reduce the amount due field in the claim form by the payment amounts entered against the invoice.
Typically, patient Primary Insurance would be automatically entered from the patient file at invoice time, the line item selected would be identified as needing to be billed to an insurance company. By placing a check mark in the line item apply insurance field ( see invoice Line item View Detail column) it automatically triggers the insurance business rules which are used to calculate the fees to be billed to the patient and to the insurance company. The calculated amounts are based on the billing rules entered by the user for the given insurance policy identified as the patient primary insurance company.
When a line item is added to an invoice, Filopto checks for three main conditions:
1) Filopto verifies if there is an Insurance policy to be associated with the line item. To do this, it verifies if the patient file has a primary insurance policy which must be applied to the invoice. If a primary insurance policy exists, it will apply the billing rules associated with the Policy automatically. It will also prepare the line item for inclusion on the claim form.
If no insurance policy is selected for the line item, it does not apply any business rules to the line item and does not prepare the line item for inclusion on the claim form and proceeds to the second condition.
2) It verifies if a Insurance Business rules exists for the item. If a rule is identified for the item, it will apply the values associated with it and does not go to the third condition. If no rule is identified, then Filopto goes to the next condition.
3) If no Insurance policy rules is to be applied, Filopto applies to the item the Retail Price listed in the inventory record for that item and for that office.
Once the invoice is completed and that any payments are recorded the user can then create the insurance claim by selected the Prepare a New Claim or the Prepare / Update button located in the invoice Claim button screen. This will create the claim.
If full payment is not received from the Primary Insurance and a Secondary Insurance carrier is available, this carrier would be entered in the Secondary Insurance field and a claim would be generated for submission to the secondary carrier. When you prepare the claim for the Secondary Insurance, all payments made up to and including the time of creation against this invoice will be used to calculate the amount due field for the claim form. The same process is repeated for the subsequent claims made to the Tertiary and Fourth insurance companies.
The Insurance Coverage Tab allows users to identify which insurance company and policy is used. Each tab can create a separate claim Invoice using the information of the invoice and the previous claim.
