Setting Copays for Insurance Plans and Policies

Fixed amount and percentage copays and patient portion in SOS G5 are set in each Insurance Plan (defaults for new policies under each Plan) but they also appear in each Insurance Policy in case you have a policy that varies from the defaults specified for the Insurance Plan. (In older versions of SOS, these settings appeared on the Patient screen.) When you first add a new Insurance Policy, SOS will automatically insert the values specified in the related Insurance Plan. You can then, if desired, make patient=specific adjustments.

Copay field defaults on the Insurance Plan screen

Normally you will review and adjust (if needed) the copay values while setting up your patient’s insurance policies, but here is how to get to these settings after the fact:

  1. From the Patient List, open the desired patient.
  2. Select the Payers tab.
  3. Select the Insurance Policies tab.
  4. Double-click the desired policy.
  5. Toward the bottom of the form you will see a section called “Copays / Deductibles“. This section will initially contain whatever values might have been entered as defaults on this policy’s Insurance Plan, but you can make any changes that might be appropriate for the current policy.
Copay settings on the patient’s Insurance Policy screen

Coinsurance is for policies in which the patient is responsible for a percent of the fee. If there is a maximum session amount covered by insurance, enter that amount in the field Max Session Charge Covered By Insurance. Any fee amount greater than than the maximum coverage limit will be the patient’s responsibility. For example, if the patient coinsurance is 20% and the fee is $150, but the maximum covered fee is $100, the patient portion will be 20% of the first $100 PLUS any fee amount greater than $100. The total patient portion, therefore, will be $20 of the first $100 plus the entire $50 above the max, that is, $70.

Be sure to review Creating a Carrier Plan Exception for another way to control how responsibility is divided between the patient portion and the insurance based on specific services.

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