Understanding Insurance Carriers, Plans, and Policies

In SOS G5 and later, insurance payers are defined as the entity from which you receive checks or electronic payments, the Insurance Carrier. A given Carrier, especially the larger ones, generally offer a variety of Insurance Plans, which specify the default details of the healthcare coverage provided to employees and other individuals through Insurance Policies.

  • Carriers write the checks. Aetna and United Healthcare are Carriers. Many patients may share the same Carrier.
  • Insurance Plans contain the default conditions of coverage, such as deductibles, co-insurance, and copays to save typing when you add new Insurance Policies for a patient. In addition, it is in the Insurance Plan that you will find Plan Exceptions. Exceptions are the key to rapid, accurate assignment of payer responsibility when adding new charge entries. Every Carrier has one or more Insurance Plans. Many patients may share the same Insurance Plan.
  • Insurance Policies include patient and insured identifying information, subscriber number (insured id), and other specifics the Carrier needs to process your claims. An Insurance Policy is unique to one and only one patient, but one patient may have an unlimited number of Insurance Policies.

The important thing to remember, starting with SOS G5, is that when setting up an Insurance Policy for a patient, you will be selecting the Insurance Plan that specifies the coverage rather than the Carrier-payer. Every Policy links to its Plan, and every Plan links to its Carrier, so when it comes time to apply payments or adjustments, the system knows which Carrier (payer) to pick.


Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes:

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>

This site uses Akismet to reduce spam. Learn how your comment data is processed.