In the normal course of events, SOS will automatically queue up claims for the secondary payer as soon as the balance on the primary insurance drops to zero due to payment, adjustment, or transfer. If there is a tertiary payer, it will follow when the secondary is completed, and so on.
The exception is when the charge fee amount is zero, but it is still necessary to generate a claim. In that case, the secondary insurance won’t generate a claim unless you manually mark the primary insurance claim for the charge as “paid.” Here is how that is done:
In the main Navigation bar, open the Claims section and click Outstanding Zero Splits.
The Outstanding Zero Insurance Splits list will appear. Tag one or more charges in the list. Use the push-pin buttons in the toolbar or the standard Windows tagging methods of click, CTRL-click, SHIFT-click and so on. In the web browser version of G5, check the boxes to the left of the desired lines.
Once you have tagged desired lines, click the dollar-sign button in the toolbar.
Any charges for which there is a secondary payer will now be queued for billing in the next insurance batch for which it qualifies.
Select Claims > Output Claims(s)… in the SOS Navigation Bar.
Find the claim batch in which your original claim was created. (Double-click the claim batch to view the specific claims in that batch to confirm that the desired claim is in the batch.)
Highlight the claim you want to reprint and click the Clear Billed Dates button to reset all the charges on that one claim. If you want to reset more than one claim in the list, tag those you want to select by holding down the <CTRL> key and clicking each one. To tag all the claims, use the Tag All (yellow map pins) button.
It is also possible to clear the billed dates on only some of the charges on a claim. To drill down to the specific charge line on a claim, highlight the claim and click the first button on the toolbar instead.
Go back to the Navigation Bar and select Claims > Create A New Claim…
Make sure you uncheck the Include Previously Billed Items option, then carefully specify the patient and date range of the services covered on the claim you want to reprint.
Once you have entered the patient and insurance information needed to submit a complete claim and you have entered and posted some insurance-billable charge entries, you can generate insurance claims.
In the navigation panel, you will see a section entitled Claims and within that section you will find a link to Create New Claim(s) – Professional. (If you are using the “Pro” version of the software, you will also have a link to Create New Claim(s) – Institutional. The procedure to generate institutional claims is very similar to that described below for Professional claims.) The screenshot below shows the options you can specify for your insurance run.
Include Previously Billed Items
Normally, an insurance batch would include only charges that have not yet been billed, but from time to time you may have a situation in which you want to include charge items that have already been billed. The first option, Include Previously Billed Items allows you to do exactly that.
You can use these options to …
Specify the date range of charges to be included.
Specify the alphabetic range of patients to be included.
Limit charges billed to a single rendering provider.
Limit Carriers to be billed to a particular Carrier Category (entered on the Carrier information screen).
Limit patients to just those assigned to a particular Patient Category on the Patient information screen.
Limit claim charges to those which you have assigned to a particular Sort Code on the Charge entry screen
These output options can be used to adjust the way the data is presented or alter data shown in particular areas of the claim. In most cases, you will probably want to check the first two options.
The Pay-To Provider option forces the system to use the Pay-To Provider address information at the bottom of the claim rather than the default address for the designated Billing Provider (Supplier). See Managing Billing Providers for more information.
Creating Your Claim Batch
Once you have set your filtering and output options, just click the Create Claims button to create your claims.
The Create Claims step gathers all the data needed for claim output, according to the options you have specified. When this step is complete, the next screen will appear, on which you will specify the specific format desired by clicking the Output Claims To… button:
If your claim output does not line up well with your pre-printed forms, you can tweak the print position up/down and/or left/right by adding the claim form to the Reports Alignment list, with the desired adjustment values.
Carrier Plan Exceptions (Plan Exceptions for short) is a way of making accurate entry of charges as efficient as possible, even if a patient has an insurance plan that requires an unusual allocation of insurance and patient responsibility or mandates a maximum allowable fee that is lower than you normally charge. (Note that in older versions of SOS, Plan Exceptions were called “Carrier Exceptions”.)
Medicare is the poster child for insurance coverage that requires special handling for each covered service, and SOS Plan Exceptions are the best way to make it quick and easy to enter Medicare charges. Let’s take a look at an example, billing for an hour of psychotherapy, CPT 90837, when the patient’s primary coverage is Medicare Part B by a Medicare participating provider (PAR):
Provider’s standard fee: $150
Medicare’s PAR Amount: $129.31
Medicare’s Actual Reimbursement Amount: $97.72
The most the (PAR) provider may charge is $129.31, so that is Medicare’s maximum allowable fee and the provider will have to write off $10.69 (the part of her standard fee above $129.31). In addition, Medicare only pays this provider $97.72 for an hour of psychotherapy, so the patient responsibility is the remaining $31.59 (max fee less insurance payment amount). The fact that these rates differ for each CPT code means that manual entry of insurance and patient portions plus the adjustment would be tedious and error-prone drudgery for every single service entered for Medicare patients. Instead, SOS’s Plan Exceptions give you a place where you can store the critical amounts one time so that the splits and adjustments can be automatically calculated for you. You just select the patient, the provider, and the service code. The software does the rest.
Plan Exceptions detail a unique combination of a specific insurance plan, service code, and type of provider. When you add a new charge entry to the daysheet, SOS takes the service code of the entry, the patient’s primary insurance plan, and the type of provider (if relevant) and checks to see if there is a match with a Plan Exception. If there is a match, the plan exception is used to determine:
How fee responsibility should be split between insurance and patient’s responsible payers.
If any part of the fee should be immediately adjusted (written off).
The CPT (and optionally any modifier) codes that should be used for claim filing.
(Pro version only) The revenue code to use on Institutional Claims.
You don’t have to fill in every field, just those that differ from the defaults on the General tab. For example, if only the CPT code to be used on claims for this payer is different from that specified in the Service properties (Common Lookups > Services), that is all you have to enter in the Plan Exception.
Copay (patient responsibility) calculation
Although increasingly uncommon, some managed care insurance coverage still employs more complex rules than those in our example above, such as escalating co-pay amounts based on the number of previous treatment visits. If that is the case for a particular Carrier Plan Exception, you should select “Authorization settings” for the Calculate Copay From field and make sure that the relevant Authorization configuration is defined appropriately in the patient’s Insurance Policy.
You can override the number of units entered on the Charge Entry form through the use of the Multiply units by value in the Plan Exception. Rarely there may be a situation in which a particular payer requires that services be reported in the claim based on a smaller time increment. For example, one payer might require you to report a treatment hour in 15-minute units, while most payers expect a “1” for the hour. In this situation you could set a units multiplier of “4” in the Plan Exception for this service/carrier plan combination. The units on your charge entry will show “1” in the Charge Entry in SOS, but come out as “4” on the claim for this payer.
Special CPT requirements
Let’s say that one of your Carrier Plans requires a different CPT code than the rest of your payers for the same service. You would then add a Plan Exception for that Plan and service shorthand code, specifying the required CPT code. Some SOS users instinctively think that they need to add a new service entry to the Services list just for Medicare patients. Not only is an alternate Service not necessary, but it would also cause problems when a patient’s primary insurance requires one CPT while the secondary insurance requires a different CPT. Use a single service entry and shorthand code for each service. Just add or adjust the appropriate Plan Exception when a special need arises.
UB Revenue Code
If you are using the Pro version of the software and file institutional claims (UB forms and/or electronic institutional claims), you also can specify a special Revenue Code when billing the service and payor designated for the current exception.
Insurance Plans are added and managed from the second tab (Insurance Plans) of the Insurance Carriers form (Billing Lookups > Carriers/Insurance Plans).
Find and open the Carrier for the plan you want to add or modify. If the Carrier does not yet exist, you can add a new Carrier.
After the Carrier form displays, click the second tab (Insurance Plans). The current plans for the selected Carrier appear in the list. If you want to view or modify a plan that is already in the list, just double-click it. To add a new Insurance Plan, click the New button just above the Insurance Plan list, or click anywhere in the list and press <CTRL><N>.
At the top of the Insurance Plan form is a required field for the Plan Name, plus a Contact, and some Remarks. Next to those fields are a set of drop fields in which you can select an address, a phone number, and an email address for this plan. The selections in the drop list come directly from the Communications list on the main Carrier screen. If what you want is not already present in the drop list, use the New button at the bottom of the list to add a new selection with the needed information. Note that if you add a new entry to any of these drop lists, whatever you add will also appear in the Communications list on the Carrier screen.
Next, there are two panels containing fields that match fields just like them on the main Carrier form. You will probably notice that default values taken from the Carrier form automatically populate these fields. Just change whatever needs to be different.
At the bottom of the Plan form are a set of fields that allow the software to calculate the appropriate patient portion of your fees. These are the values that often differ from plan to plan among those offered by the same Carrier, so communication with the payer is often required to determine how these fields should be completed.
Once a new Plan has been saved, and the Plan’s Carrier has also been re-saved, you will be able to go back into the Plan to specify Plan Exceptions.