Examples of Editing Plans

A patient’s Insurance Plan can be edited by selecting their name on the Patient Lookup and clicking on GoTo on the menu bar. Select either Primary or Secondary Insurance Plan. This can also be done from their Patient Information screen. The patient’s Insurance Plan can be also be edited from their Transaction screen.

The following examples of editing an insurance plan are helpful when setting up capitation plans. You may have plans that follow these same examples, or you may need to set up a plan using a combination of these examples.

Note: Do not leave the Ded. (deductible) column blank. Enter an “N” if there is no deductible for this treatment, or a “Y” if the deductible is to be applied.

EXAMPLE #1: If the patient is responsible for the entire fee, enter the amount of the capitation fee under the Fee column. Enter 0 under the P.Cov% column. The P.Max column can be left blank. The fee will appear as the patient portion due on the Transaction screen. In this example, the patient will be charged $25.00.

EXAMPLE #2: The UCR% column is only used when a percentage of the doctor’s usual fee must also be calculated and added to the patient portion. You will enter the amount of the patient co-pay under the Fee column. The percentage amount that is entered under the UCR% column will be added to the patient’s co-pay and will appear as part of the patient’s portion on the Transaction screen. In this example, the patient will be charged $25.00 plus 5% of the doctor’s usual fee.

EXAMPLE #3: If there is no charge for the service, type NC under the Fee column. The P.Cov% and P.Max columns can be left blank. The Transaction screen will then show $0.00 under the fee column for this service. Tip: You can double click on the Description when you are in the Transaction screen if you would like to add “N/C” to the description!

EXAMPLE #4: If the insurance and the patient both pay an amount of the fee, you will enter the total amount of the insurance portion and patient portion under the Fee column. Enter a percentage under the Cov% column and the dollar amount that the insurance company will pay under the P.Max column. The difference between the Fee and the P.Max column will appear on the Transaction screen as the patient portion. The amount in the P.Max column will appear as the insurance portion.

Note: You must enter a coverage percentage under the Cov column when there is a maximum. If you enter a zero here, it will change to 100% when you save.

EXAMPLE #5: If the insurance pays a percentage of the fee and the patient pays the difference you will enter the amount of the capitation fee under the Fee column. Enter the percentage that the insurance pays under the P.Cov% column and 0.00 under the P.Max column. In this example, 80% of the fee will appear as the insurance portion. The remainder will appear as the patient portion on the Transaction screen.