Eligibility Rules Setup
Summary:
Use of "Eligibility Rules" can allow you to track frequency/allowances eligible for certain procedure codes or a range of procedure codes.
This particular area is most often used in the French version of the program for RAMQ eligibility. This use is NOT described here.
Instead, the use of "Eligibility Rules" in conjunction with scaling is discussed here.
Clients often ask if the system can be setup to warn you when the patient has gone over their maximum of allowed scaling units per year.
The following scenario is based on a patient whose insurance allows 12 units of scaling per calendar year.
NOTE: that this utility only works in provinces that use RVU factors in billing. Ontario is one of them. Not straight fees.
Steps:
To setup the eligibility rules in Windows:
1. File>Update>Insurance>Eligibility.
2. Choose the Insurance Plan from the drop-down list.
3. :Add" code, we will use 11111 (one unit scaling), click OK.
4. Enter "Range Ends" as 11119 (one additional unit scaling).
5. In field of "Eligibility Rule" enter: U:12/1Y, click OK.
6. The "Setup Coverage" area of the patients insurance plan information must also contain the correct "Anniversary Date" information, in this case: 01/01 (Jan 01).
Now the system can track the patient's scaling units used. Once the 12 units of scaling have been billed for the year, the next attempted scaling bill will give a warning.
In order to force the warnings to appear at the appointment booking stage, you must follow these directions:
1. Add the appointment into the scheduler.
2. While in the "Appointment edit" window, click the "Services" tab.
3. Then click on Add button, and click on Services for Appointment Date.
4. Enter the scaling procedure code to be done for this next appointment.
As soon as the code is entered, if the number of units exceeds the maximum allowed, the Eligibility Rule warning will appear.
At this point the patient could be told ahead of time that the appointment may/may not be covered by insurance.
Product (s): ABELDent version 5.01B06
Category: Insurance
Classification: Public
Date Created: 10/99
Created by: RL