Add and Manage Insurance Information

An insurance set must be created for every patient, regardless of whether they have commercial insurance or will be using private pay. Each insurance set contains an effective date, a primary payer, and policy/benefit information.

User Permissions

Admin-level users can inherently create and manage insurance information for patients. Managing Organization users, as well as Organization users, will require edit-level permissions under the Insurance Access section of the Permissions tab in their respective profiles. For more information on user permissions, click here.

Create an Insurance Set

Let's review the workflow for creating an insurance set. For information on verifying eligibility after the insurance set has been created from both the RCM and EMR, click here.

Use the instructions below to begin creating an insurance set directly in the RCM!
1. Navigate to the Patients section and locate the desired patient.
2. Then click the Intake quick link to be redirected to the patient's most recent treatment episode.
3. Next, click the Insurance tab.
Use the instructions below to begin the process of creating an insurance set using the EMR-RCM integration!
1. In the patient's chart, click Edit.
2. Scroll down to the Payment Method section and select the desired method of payment.
3. Then click Manage Insurance.
4. The iframe to the RCM will open, and you can manage insurance information.
5. After following steps 4-12 below, click Close and Refresh to complete the process.

In the Insurance sub tab, click Create Insurance Set.
Enter the effective date and click Create. As a best practice, we recommend using the admission date as the effective date to avoid disruption to the billing process.
Next, click [Create] under the primary header.
Then select the payer's name from the drop-down, and click Select. If the payer does not exist in the RCM, click Add New Payer. For more information on adding new payers, click here.
Next, click on the the payer name to open the set.
In the insurance set, click the Policy Holder tab.
Then click Edit.
Enter the Subscriber ID and update the Patient Relationship to Subscriber drop-down.

Note: Any selection other than Self will require additional subscriber information to be included.
After you have entered the required information, set the Verify Eligibility on Save toggle to enabled to instruct the system to run an eligibility check for the patient. For more information on eligibility checks and responses, click here.
When you're done, click Save.

Note: After a primary payer has been established, follow steps 6-12 under the secondary or tertiary headers.

Enter Private Pay Information

For organizations that use the Patient Billing module in the RCM directly, the patient's payment method can be updated by selecting Set to Private Pay in the Intake > Insurance subtab of the patient's treatment episode.

Using the EMR+RCM Integration

1. After finishing the patient creation process outlined here, scroll to the Payment Method section of the EMR.
2. Click Private Pay (This field is customizable and may vary based on your organization's nomenclature).
3. Next, click Manage Insurance.
4. In the iframe, click Set to Private Pay.
5. Then click into the Scheduling and Utilization tab.
6. From there, click on the Service Rates subtab.
7. Follow the steps outlined here.
8. Finally, click Close and Refresh to complete the process.

Manage Insurance Information

Situations may arise that require a change to the patient's insurance information. Let's review some everyday situations and how to address them.

Note: Organizations using the EMR+RCM integration will follow the exact instructions listed below once the user is in the iframe.

If the patient has a carveout, follow steps 1-8 listed above, then locate the desired carveout and click Change.

Pick the desired carveout payer from the drop-down and click Select to complete the process.
To instruct the system that an insurance set is no longer valid, use the steps outlined below:
1. Navigate to the Patient > Treatment Episode > Intake > Insurance.
2. Under the Termination Date column, click Add.
3. Enter the desired termination date and click Save to complete the process.
If the wrong insurance was billed, use the following steps to correct the claims:
1. Follow the workflow for adding a carveout payer to an insurance set. Note: this process must be repeated for each field when no carveouts are present.
2. Once the correct payer information has been updated, follow the correction process outlined here to resubmit the claims (as new) to the proper payer and complete the process.
The most essential step in creating an insurance set using a paper payer is ensuring that a mailing address is configured in the RCM. This can be done in two places - the Practice Admin and/or the patient's insurance set.
- To confirm this information, an admin-level user should confirm that a mailing address is present in the payer's profile under the Practice Admin > Payers section of the RCM.
- If one is not present, the address can be added/altered using the instructions below:
  1. Navigate to the Patient > Treatment Episode > Intake > Insurance > Insurance Set > Payer section.
  2. Next, click Edit.
  3. Locate the payer whose address you wish to alter and toggle off Use Practice Payer Address.
  4. Enter the mailing address you'd like the paper claim to be sent to and click Save to complete the process.
Reset the Patient Record
1. Delete the Prospective Patient in the RCM
  - Navigate to the Patients section and update the Episode Status filter to Prospective.
  - Next, click on the patient's name to open their profile.
  - In Treatment Episodes tab, scroll to the right and click Delete.
  - Then select the Profile tab and click Delete
2. Remove the External App in the EMR
  - Open the patient chart and select Edit Patient.
  - Scroll to the External Apps section and click Delete External App.
3. Delete EMR Insurance
  
  Record the insurance details before deleting—you will need them to recreate the insurance in the RCM.
  - Click Delete Insurance in the Insurance section.
  - Confirm by clicking OK.
4. Recreate Insurance
  - Follow the instructions outlined here to recreate the patient's insurance profile.
If the patient’s policy was recorded with the incorrect effective date or another policy should have been active, you can edit the Insurance Set's Effective Date.
1. In the Patients section of the RCM, locate the patient and click the Intake quick link.
2. Next, click the Insurance subtab.
3. Then click the effective date you wish to change.
4. Update the Effective Date field to the desired date, then click Save to complete the process.
Note: Any claims submitted with the previous effective date (as well as those that were not but were already submitted) will generate corrections when the date is changed. For more information on corrections, click here.
Let's review how to remove a secondary or tertiary payer!
1. In the Patients section of the RCM, locate the patient and click the Intake quick link.
2. Next, click the Insurance subtab.
3. Next, locate and click the payer name you wish to remove.
4. In the Payer tab of the insurance set, click the Delete button to complete the process. Keep in mind that if the patient also has a tertiary payer, deleting the secondary payer will move the tertiary payer into the secondary position.
Note: Any claims submitted with the secondary and/or tertiary payer information will generate corrections when the payer is deleted or changed. For more information on corrections, click here.