Insurance Eligibility Warning Setup
Summary:
The setup of "Eligibility Rules" allows offices to track the frequency allowed for specific procedure codes or ranges of procedure codes. The system will then warn the user of the patients status of ineligibility if the patient will be going over their maximum allowed for the year on the specific procedure codes. This type of warning is particularly helpful with regards to scaling units allowed per year. This document is therefore based on a scenario of a patient whose insurance allows 12 units of scaling per calendar year.
Steps:
1. Open ABELDent
2. From the toolbar, select File, Update, Insurance then Eligibility.
3. The Procedure Eligibility Update window will display.
4. From the Select Plan drop down list choose the appropriate Insurance Plan from the list of choices. In this sample, is referred as PLAN ID "A"
5. Click the Add button.
6. The New Starting Range window displays.
7. At Enter New Starting Range enter the required procedure code. This example will use code 11111 (one unit scaling), click OK.
8. At the field Range Ends enter the required procedure code. This can be the same code as the Starting Range code or the end of that range of procedure codes. This example uses a range of scaling codes, therefore the code Range Ends is entered as 11119.
9. In field of Eligibility Rule enter the unit/year rule, click OK. The sample uses this rule: U:12/1Y
- The sample rule indicates that this range of procedure codes allows 12 units (U) of scaling in total per calendar year (Y)
- Another option would be an "A" year entry, which refers to anniversary date. These calculations would then be based on the anniversary date setup in the patients' insurance plan details. U:12/1A would indicate that a total of 12 units (U) may be performed per plan anniversary date.
- There is no option for those plans on a rolling year setup
10. Do not enter information into any other fields
11. ABELDent will now track scaling units allowed for patients attached to insurance Plan ID "A".
How ABELDent Uses Insurance Eligibility Warnings During Service Entry Stage1. Patients using Insurance Plan "A" will receive a warning message when you attempt to bill anything over the 12 units of scaling during this calendar year. The next attempted billing of a scaling code would result in the following warning message: "A Maximum of 12 units are covered every Year. There has been xx.x units performed since day/mo/yr including this procedure. The last occurrence prior to today was day/mo/yr. This service may not be covered. Touch Y to continue".
How ABELDent Uses Insurance Eligibility Warnings During Appointment Booking Stage
1. The user has ensured that Insurance Plan is setup with Eligibility Rules as outlined in section I of this document.
2. ABELDent will warn the user of scaling eligibility during the appointment booking stage by entering planned services during appointment setup.
3. Add an appointment into the scheduler.
4. The "Appointment Edit" window displays, enter in the appropriate appointment information.
5. Click the Services tab.
6. Select Services for Appointment Date and click the Add button.
7. Enter the scaling procedure code planned for this next appointment. NOTE: the entry Type will be displayed as a P-Predetermination. Tab.
8. As soon as the code is entered, if the number of units exceeds the maximum allowed, the Eligibility Rule warning will appear: "A Maximum of xx units are covered every Year. There has been xx.x units performed since day/mo/yr including this procedure. The last occurrence prior to today was day/mo/yr. This service may not be covered. Touch Y to continue".
9. If the service does exceed the maximum allowed, the service entry will not be saved.
10. At this point the patient could be told a head of time that the appointment may/may not be covered by insurance.
Product (s): ABELDent
Category: Insurance
Classification: Public
Date Created:
Created by: LRE