A practice in a non-real-time system retrieves the coinsurance amount from the contract exception, contract library, or previous transaction details. In a real-time system, the coinsurance amount is retrieved from real-time eligibility (271) transaction file.
Coinsurance amount from real-time response information
A real-time system can fetch the coinsurance amount for cost estimation from the real-time response of the latest eligibility verification. Your practice preference settings must be set to fetch the coinsurance amount from the real-time response.
Coinsurance amount from previous transaction details
The coinsurance amount can be fetched from previous financial transaction details in real-time and non-real-time systems. Also, your practice preference settings must be set to fetch the coinsurance amount from the transaction details. The system fetches the coinsurance amount found in the latest financial transaction made in one year or specified date range. If you are the administrator, you can specify the date range in the practice preferences.
Coinsurance amount from contract library or contract exception
Coinsurance amount can be fetched from contract library or contract exception in real-time and non-real-time systems. The coinsurance amount from the contract library or contract exception is calculated based on the reimbursement percentage you want to receive from the participating provider and the allowed amount.
If you are the administrator, you must configure the following settings in File Maintenance:
- You must apply prorate insurance balance.
Note: It is mandatory to apply prorate insurance balance for fetching the coinsurance amount from contract library or contract exception.
- You must select Prorate Insurance Balance for the selected contract payer in the Modify Payer Information window in payer master file.
- You must select Prorate Insurance in the General tab of the Contract Library Maintenance window.
- You must select the desired managed care contract to associate with the payer in the payer master file.
In File Maintenance, open Master Files, then select System and then select Payers. For a new payer, the Add Payer Information window opens or you can select an existing payer and open the Modify Payer Information window. You can then select a contract from Managed Care Contract.
- You must select the participating provider to participate in the selected managed care contract for the payer in the payer master file.
In File Maintenance, open Master Files, then select System and then select Payers. For a new payer, open the Add Payer Information window or select an existing payer and open the Modify Payer Information window. You can then select a provider from Participating Providers.
- Set the fee schedule for CPT®4 codes in the contract exception or contract library.
In the Contract Library Maintenance window or Contract Library Maintenance window, you can enter either the percentage or amount of allowed amount that you expect to receive for services rendered by the participating providers in the % or the Reimbursed field under Participating.
- The coinsurance amount is obtained from the contract library or contract exception if your practice preferences are set up to fetch the coinsurance amount from the contract library. When you request for cost estimation on the Estimate Patient Cost window, the coinsurance amount is displayed automatically.
- The coinsurance amount shows blank when any one of the following conditions is true:
- Prorate insurance balance is not selected for the contract payer in the payer master file.
- Prorate insurance is not selected for the contract in the contract library.
- Participating provider reimbursement is 100%.
- Co-pay is applied to the CPT®4 code and the co-pay amount is displayed on the Estimate Patient Cost window.
- The coinsurance amount is calculated as the difference of the allowed amount and amount of the participating provider reimbursement if the following conditions are true:
- Prorate insurance balance is selected for the contract payer in the payer master file.
- Prorate insurance is selected for the contract in the contract library.
- Participating provider reimbursement is less than 100% or blank.
- Co-pay amount is blank on the Estimate Patient Cost window.
Note: After estimating the cost on the Estimate Patient Cost window, the coinsurance amount in the estimate is not updated back to the contract exception or contract library.
