Insurance and self-pay coverage

The Coverage tab on a patient's chart lists every insurance plan and self-pay arrangement on file. Coverage that is active today shows first, in billing order (primary, secondary, tertiary), then coverage that starts later, then coverage that has ended. Click a column header to sort by it instead.

You need a role that can manage patient coverage to add, change or delete coverage. Anyone who can open the chart can see it.

Add a coverage#

1. Open the patient's chart and click the Coverage tab.
2. Click Add Coverage.
3. Choose the Payer: type part of its name to search your clinic's active payers in Setup (see Payers). If the payer list does not load, the dialog says so and offers Retry.
4. Choose the Priority: Primary, Secondary or Tertiary.
5. Enter the Member id from the insurance card, and the group number and plan name if the card shows them. Choose the Network status: whether the plan treats your clinic as In network, Out of network or under a Single case agreement, or leave it Unknown until you confirm it.
6. Enter the Effective date and, if the plan has ended or will end, the Termination date.
7. Fill in the subscriber, cost sharing, benefit limits and EPSDT sections as needed (see below), then click Add Coverage.

To change a coverage, open the row's menu and click Edit. To remove one entered by mistake, click Delete and confirm; the chart's change history keeps a record of it. A coverage with authorizations on it, or one already used on visits, charges or claims, cannot be deleted. When a plan simply ends, enter its termination date instead of deleting it, so past visits still show what covered them.

Billing order and dates#

Both the effective date and the termination date count as covered days. A coverage with no termination date stays in force until you end it.

On any one date of service a patient can have only one primary, one secondary and one tertiary coverage. If you try to save a coverage whose priority is already taken on some of its dates, NeatPractice refuses the save and asks you to end the other coverage first or choose another priority. To switch a patient to a new primary plan, enter a termination date on the old plan and give the new plan an effective date after it.

The subscriber#

The subscriber is the person who holds the insurance. Choose the Patient's relationship to the subscriber:

• Self: the patient holds the plan. NeatPractice fills in the patient's name, date of birth, sex and address.
• Spouse, Child or Other: choose the Subscriber from the patient's contacts. NeatPractice fills in their details, gives that contact the Insurance subscriber role and, if their contact record has no date of birth or sex yet, copies them from the coverage.

Correct the subscriber's details so they match what the payer has on file; claims print them as entered. Later changes to the contact do not change the coverage. A contact who is the subscriber on a coverage cannot be deleted, or lose the Insurance subscriber role, until you choose another subscriber on that coverage.

For a minor, the subscriber is usually a parent or guardian with the relationship Child. Add the parent on the Contacts tab first (see Contacts and guardians).

Cost sharing#

Record what the plan expects the patient to pay:

• Copay per visit ($) for plans with a flat copay.
• Coinsurance (%) for plans that pay a percentage.
• Deductible ($) and Deductible met ($), and Out-of-pocket maximum ($) and Out-of-pocket met ($).
• Amounts met as of: the date the met amounts were true on, such as the day you called the payer.

NeatPractice uses these amounts to estimate what the patient owes for a visit. The payer's remittance decides the final amount. Instead of typing them, you can copy them from an eligibility check (see Eligibility checks).

Benefit limits#

Some plans cap the number of visits or dollars in a period, for example 20 visits a calendar year shared by speech therapy and occupational therapy. Click Add Limit and enter:

• Limit: the number of visits (a whole number) or dollars.
• Counted in: Visits, Hours or Dollars.
• Resets every: Calendar year, Plan year (starting each year on the coverage's effective date) or Lifetime.
• Disciplines: the disciplines that share the limit. Leave it empty when every service counts toward it.

The Benefit limits column on the coverage list shows how much of each visit limit the current period has used: visits documented on the coverage (voided ones do not count) plus appointments already booked on it. When a new appointment would go past a visit limit, the schedule warns before you save it; you can still book it, for example when the plan has approved extra visits. Hour and dollar limits show their amount only.

EPSDT and family planning#

For Medicaid plans that need them, click Add Discipline under EPSDT and family planning and, for that discipline's services, check EPSDT service with its EPSDT referral code, or Family planning. Claims for that discipline carry these indicators. Each row needs a discipline.

Medicare as a secondary payer#

When a Medicare plan is not the primary coverage, choose the Medicare secondary payer type that explains why another payer pays first, such as Working aged (employer group health plan). The field shows only for Medicare plans; switching to another payer drops the choice.

Self-pay#

Choose your clinic's Self-pay payer to record that the patient pays for their own care. A self-pay coverage needs no member id or subscriber: the patient is recorded as the subscriber, and plan, cost sharing, benefit limit and EPSDT values typed before you switched to self-pay are not saved. Enter a Self-pay discount (%) if the patient pays less than your standard charges; the discount applies while self-pay is the primary coverage.

Network status#

The Network column shows each plan's network status. An out-of-network plan is usually billed with a superbill the family sends to their insurer, or a courtesy claim. A single case agreement bills like in network for this one patient. Superbill runs can pick out every out-of-network patient for a date range.

Billing readiness#

Open a coverage's menu and click Billing Readiness to see what keeps it from being billed today. Each check shows whether it is met, with a Fix link where it is not:

• Payer setup: the payer has a payer ID for electronic claims (or a claims address for paper claims) and a rule set in force. Fix opens the payer.
• Member ID: the coverage has the member ID from the card.
• Network status: the plan's network status is known.
• Eligibility: an eligibility check came back active in the last 30 days. Payers that take no electronic checks pass without one.
• Authorization: when the payer's rules ask for authorizations, an approved one covers today. Fix opens the Authorizations tab.
• Enrollment: for each provider on the patient's care team, whether they are enrolled with the payer today and their network status. When the payer requires enrollment for claims, a provider who is not enrolled blocks billing. Fix opens the provider.

A self-pay coverage shows one check: the patient is billed directly, so no claim is needed.

Change insurance#

When a patient's payer changes, for example a new employer plan, use Change insurance instead of editing the old coverage, so billed visits stay with the payer that was billed and upcoming care moves to the new one. You need roles that can manage both coverage and authorizations.

1. Open the coverage's row menu and click Change insurance.
2. Check the Effective date: the first date of service billed to the new payer. It starts as the day after the last billed visit. The dialog shows that last billed visit and how many upcoming appointments and unbilled visits will move; the counts update when you change the date.
3. Choose the New payer and enter the Member id and Group number. The member id is required for every payer except self-pay, which asks for neither. Turn on Has a plan name to add one.
4. Under Approvals, each authorization that runs past the date lists what is left on its lines. Choose:
   • Transfer what is left: the approval ends the day before the change, and a copy under the new payer carries what is left from the change date to the old end date.
   • End it, new approval to follow: the approval ends the day before the change; add the new payer's approval on the Authorizations tab.
5. Click Change Insurance. A message confirms how many appointments, visits and authorizations moved.

The old coverage ends the day before the change and a new coverage with the new payer takes its place. Billed visits never change. Every upcoming appointment from the date moves, including each occurrence of a recurring series, and picks its authorization again under the new payer. If an upcoming visit would be left with no authorization covering its codes, the change stops and says how many; transfer the approvals or enter the new ones first, then try again. This works the same for every discipline.

When a whole plan changes hands, for example every patient of one Medicaid plan moving to another, move them all at once from Setup > Payers (see Move patients to another payer).

Insurance card#

Open a coverage's row menu and click Insurance Card to see the photos of the card. Click Upload Front or Upload Back and choose a PNG or JPEG of 5 MB or less, such as a phone photo or a scan. Replace swaps a photo and Remove takes it off the coverage; while one is saving, the other waits. If a photo does not load, click Retry. Anyone who can open the chart can view the card; adding or removing photos needs permission to manage coverage.

Find a patient by member id#

The patient list search also matches the start of a coverage's member id (see Find a patient). Member ids never appear in the patient list itself.

ABA benefits#

When your clinic has the ABA module, the Coverage page also lists ABA benefits for each insurance coverage: whether the plan covers ABA, whether it needs prior authorization, who manages ABA for it, the ABA hour or visit limits, and when the benefits were verified. See ABA intake.

Case leads#

The Coverage page lists Case leads: for each coverage, the provider used as rendering or supervising provider on that payer's claims, for any discipline. Choose Set case lead on a coverage when the payer bills under the supervisor. Only active providers who practice a discipline of one of the patient's open episodes can be named; choose No case lead to clear it. Setting it needs Coverage: Manage.