Benefit Plans

For each insurance plan that you invoice, the Benefit Plan identifies the claims adjuster, the billing address, and discount information.

A plan may be used by more than one client, so the ID code typically describes the insurance carrier, not the employer using it (unless the employer is self-insured). A workable system might be to devise plan names that identify the office where bills and correspondence will be sent. You might include the letters WC in the ID code of a claims office that only handles worker's compensation claims. The ID code field holds 12 characters.

Label	Description
Benefit Org ID	ID that links to the Benefit Organization table to describe the insurance organization's full name. Use F5, Add to create this linked information when needed.
Plan ID	A linking ID to identify this plan on invoices, matching the invoice to the applicable insurance.
Benefit Type	Identifies the plan type as Insurance, `HMO`, `PPO`, `MCO` or `TPA` in this field.
Active	Indicates the plan's status. When the box is checked, the status is `Active`. On an add record, this is checked by default. This is especially useful when excluding inactive records in search lists and reports.
Send to ID	For electronic billing, the ID of the clearinghouse that will receive electronic invoices for this plan, see EDI Destinations.
Payer ID #	For electronic billing, the ID number assigned to this plan by the clearinghouse.
ICD10 Date	Effective date of ICD-10 code use for this plan.
Affiliation Requirement	If the insurer described by this plan does not require registration numbers for providers, leave this field `blank`. If the insurer gives every provider a unique PIN and/or Group number, choose `1` so that the invoice (1500 Claim Form-HCFA box 33) will show the PIN of the provider who attended the patient. If this insurer only requires some providers have registration numbers, choose `2`. Then when a provider is unregistered, the PIN number of the supervisor is used instead. The Staff ID of the correct supervisor is stored in the Billing Provider field of the Medical Staff table. Provider's registration numbers are stored in the screen accessed via the Affiliations button in the Medical Staff table. For more information, see Staff Affiliations.
FEIN	Federal Employer Identification Number.
Plan Name	Full name of plan. Defaults from Benefit Organization, change to be more descriptive if possible, to assist users in choosing the correct plan. Is using SYSTOC_EDI to send bills to bill Blue Cross or Blue Shield, be certain the plan name contains these words, or BCBS.
Claims Adjuster	The department that receives the invoice, copies automatically to the Attention field in the billing address. Use a generic name rather than an actual person.
Special Instructions	The contents of this memo appear on the Rehabilitation screen (located under Injuries) to assist the biller.
Email	Optional field to store email address of contact.
Discount %	Standard percentage discount you wish to give this plan, if any. See Discounts and Reimbursable Amounts for more information.
Disc Table	Customized table of discounts for this plan. See Discount Table Fees for more information.
Co-Insurance %	Optional, percentage of cost the plan policy covers.
$ Deductible	Optional, deductible amount for the plan policy.
Plan Type	Optional field for abbreviations such as MED, PRIV, WC, etc. If using SYSTOC_EDI, and Insurance Type is `O` (Other), stores required claim filing indicator as follows:
		`09`	Self-pay
		`10`	Central Certification
		`11`	Other Non-Federal Programs
		`12`	Preferred Provider Organization (PPO)
		`13`	Point of Service (POS)
		`14`	Exclusive Provider Organization (EPO)
		`15`	Indemnity Insurance
		`16`	Health Maintenance Organization (HMO) Medicare Risk
		`AM`	Automobile Medical
		`BL`	Blue Cross/Blue Shield
		`DS`	Disability
		`HM`	Health Maintenance Organization
		`LI`	Liability
		`LM`	Liability Medical
		`OF`	Other Federal Program
		`TV`	Title V
Insurance Type	Identifies the type of insurance plan.
		`M`	Medicare
		`D`	Medicaid
		`C`	Champus
		`V`	Champva
		`G`	Group Health
		`F`	FECA
		`O`	Other
	If using `O` with SYSTOC_EDI, see Plan Type , above, for required additional information.
Annual/Lifetime	Optional, Annual or Lifetime deductible.
Billing Address	A billing address will be created automatically when you save the form. If necessary, you can change it by selecting the Edit Bill Address button.