Retrieving Patient Benefits for Cost Estimation
Co-pay, deductible, and coinsurance are collectively referred to as patient benefits.
- Co-pay is the fixed amount the patient must pay for each visit, which is predetermined in the co-pay clause of the insurance policy.
- Deductible is the fixed amount a patient must pay each year before the insurance payer begins to cover the costs. After the patient pays the deductible amount as per the insurance plan, the payer starts to share the cost of the service.
- Coinsurance is the fixed cost for treating the covered services that the patient must bear after the deductible amount is paid.
- Non-covered charges are incurred on services that do not have insurance coverage.
For a practice running in a real-time system, co-pay, deductible, coinsurance, and non-covered charges are retrieved from the real-time eligibility (271) transaction file.
For a practice running in a non-real-time system, the patient benefits are retrieved as follows:
- The co-pay is retrieved from the patient's insurance information, contract exception, or contract library.
- The deductible is retrieved from the patient's insurance information.
- The coinsurance is retrieved from previous financial transaction details, contract exception, or contract library.
- The indication for a non-covered service is retrieved from the SIM library in File Maintenance. If non-covered, the charge amount of the service line item is considered for estimation.
The following workflow illustrates how patient benefits are retrieved to evaluate the patient cost:
