How SOS Calculates Charge Splits

Once you have selected a patient in the top of the Charge form, SOS will create a Charge Split for all available payers linked to the current patient. Charge Splits are created for all non-insurance payers as well as for any of the patient’s insurance policies that are active on the date of service that you specified.

Expected Charge Split does not appear

If an expected policy does not appear among the created charge splits, there are several likely reasons:

  • The date of service is after the date specified in the policy Coverage Ends field.
  • The date of service is before the date specified in the policy Coverage Begins field.
  • There is an Carrier Plan Exception for the current service, and the option which the option “Never bill this insurance .
Check the Coverage Begins and Coverage Ends dates.
Check for a relevant Plan Exception with the Do Not Bill This Service option checked.

If you make any changes on a payer screen to correct a missing split, be sure to fully save the changed Payer, Policy, or Carrier Plan Exception, then return to the charge and click the Recalculate Splits button in the toolbar above the Charge entry form.

Recalculate Splits button

Settings you should check if calculated split amounts are unexpected

Automatic Charge split calculations are based on your configuration of the following:

  • Carrier Plan Exception
    • Where: Common Lookups > Services. Open Service used in your Charge entry. Select Carrier Plan Exceptions tab in lower part of the Service screen. Double-click the insurance plan for patient’s primary coverage. (If not found, go on to Managed Care Authorization section.)
    • Setting:
    • Remarks: An Exception is used ONLY if the service is the one selected in the Charge and the insurance plan matches the patient’s primary insurance policy, and the Provider Type is blank or matches the provider type of the rendering provider in the Charge. If all those match, the setting indicated by the arrow in the figure above determines how SOS will continue with the calculation. If there is no matching Exception, the copay will be determined by other settings below.
  • Managed Care Authorization
    • Where: Patients > Patients – Billing OR Patients – All Data. Highlight desired Patient. Select Patient Insurance Policies from the Patient Lists shortcut in the top toolbar.

      Open the primary insurance policy. Click the Managed Care Auths tab. On the Auths list, find the active Auth that would be relevant for the service and provider on your Charge entry. Double click to see the details. If there is no relevant Managed Care Auth, then copay will be determined by other settings below.
    • Setting: The amount of the copay will be based on the Auth Copays entries at the bottom of the MC Auth screen.
    • Remarks: There can be different authorization amounts or percentages based on the visit number of the current Charge entry.
  • Insurance Policies
    • Where: Patients > Patients – Billing OR Patients – All Data. Highlight desired Patient. Select Patient Insurance Policies from the Patient Lists shortcut in the top toolbar.

      Open the primary insurance policy.
    • Setting: You can set a co-insurance percentage, with optional max session charge, or a fixed copay amount.
    • Remarks: If neither Carrier Plan Exception or MC Auth settings are applicable, these policy settings will be used.
  • Non-insurance Payers
    • Where: Patients > Patients – Billing OR Patients – All Data. Highlight desired Patient. Select Patient Payers (or Non-insurance Payers) from the Patient Lists shortcut in the top toolbar.
    • Setting: Check to see if the values in the Percent Pays column are all zero.
    • Remarks: Normally the values in this column should total to 100 percent, and the amount of the copay will be split appropriately. SOS permits you to set them all to zero, but if you do, then regardless of all the other settings above, no copay amount will be allocated to the non-insurance payers and the entire fee will be the responsibility of the insurance payers.

How copayment amounts are calculated

Warning! The following is a close-up tour of the Copay Sausage Factory, and therefore not for the faint-of-heart. Proceed at your own risk.

The diagram below shows graphically how OM determines the copay (patient portion) amount during the entry of new charges.

Decision tree used to determine the copay amount for a Charge entry.
  1. SOS starts by checking to see if the selected patient has any insurance policies that are currently active. “Currently active” means that the service date for the Charge entry falls between the start and end dates of the policy. The active policy that appears highest in the patient’s policy list is considered the primary coverage. The next active policy is considered the secondary, and so on.
  2. If there is insurance coverage, SOS checks for a Carrier Plan Exception (on the Carrier Plan Exceptions tab of the Service Form) that matches the service, provider type, and patient’s primary insurance.
  3. If there is a relevant Carrier Plan Exception (one that matches the service, patient’s insurance coverage and the provider type of the Charge entry), see if the copay calculation method on the Exception is set to option “Policy MCAuth copay settings”. If the MCAuth calculation method is selected, and the MCAuth contains copay information, then that information will determine the copay amount. To see if there is an applicable authorization, SOS must check the MC Auth details on the patient’s insurance policy to determine authorization status, covered dates, number of visits already used, total fees already used, and the services and providers covered. If there is an authorization that meets all these criteria, then SOS checks to see if you have set any copay limits. If so, it will set the copay amount to the appropriate value, based on the number of sessions that have already been linked to this authorization.
  4. On the other hand, if the Carrier Plan Exception specifies the “Policy copay settings” calculation method, that method will be used instead, unless there is no insurance policy copay information. In that event, the copay will be the Max allowable fee minus the Plan pays amount on the Carrier Plan Exception window, if these amounts are specified.
  5. If there is no relevant Carrier Plan Exception, SOS will check for an applicable MCAuth, as described above, and use it if one is found.
  6. If there is no Exception and no MCAuth, then the copay settings in the primary insurance policy will be used to determine the copay amount.

In the event that there is more than one non-insurance payer, this calculated amount will be divided among the non-insurance payer charge splits in accordance with the responsibility percentages you set for the various non-insurance payers assigned to this patient.

Non-insurance payers and percent responsibility

Note: If the selected service does not have the Include on claims option checked, or there are no currently active insurance policies, then the entire fee will be charged to the patient or other non-insurance payer(s).