Coverage plans and covered services

Coverage Plans and Covered Services

A coverage plan is a contract between your facility and an insurance company that specifies which services are covered, at what cost-sharing rates (deductibles, copays), and any limits. You must define plans before patients can bill against them.

Before you start

• You have created the insurance company (see "Adding insurance companies").
• You have Admin permission or a custom role with Insurance setup access.
• Know the plan name, benefit type (e.g., "General Coverage," "Emergency Only"), and any cost-sharing rules.
• Have a list of services (medical procedures, tests, consultations) that are covered under this plan.

Steps

Adding a coverage plan

1. Go to Settings → Insurance and select the Plans or Coverage Plans tab.
   Open in Usystems

2. Click Add Coverage Plan or the + button.

3. Enter the plan details:

   • Plan Name: A descriptive name (e.g., "Gold Health Plan," "Basic Coverage").
   • Insurance Company: Select the company this plan belongs to (from your insurance company list).
   • Plan Code (optional): An internal reference code (e.g., policy number).
   • Description: Brief details (e.g., "Covers hospitalization and major procedures").

4. Set cost-sharing rules (if applicable):

   • Deductible: The amount the patient pays before the plan covers costs.
   • Copay: Fixed patient payment per service (if flat-rate).
   • Coinsurance: Percentage the patient pays (e.g., 20% patient, 80% insurer).
   • Out-of-Pocket Maximum: Highest annual amount the patient pays.

5. Click Save to create the plan.

Adding services to the plan

1. Once the plan is saved, select it and click Add Services or a similar option (the exact label may vary).

2. From the list of available services, check the boxes for each service covered under this plan:

   • Medical consultations
   • Surgical procedures
   • Lab tests
   • Imaging (X-rays, ultrasound, etc.)
   • Emergency services
   • Other relevant services for your facility

3. For each service, you may set:

   • Benefit Amount: Maximum the plan will pay for that service (e.g., $500 for an MRI).
   • Patient Responsibility: Copay or coinsurance percentage for that specific service.

4. Click Save or Done to apply the changes.

Accounting impact

When a patient with this coverage is billed:

• The system calculates the portion the insurance company pays (based on benefit limits and copay rules).
• The patient's responsibility (copay + deductible + coinsurance) appears on their invoice.
• Medical revenue is recorded when services are delivered; insurance claims and patient payments are tracked separately.

Tips & common mistakes

• Review your plan before launching: Verify all covered services and cost-sharing rules match the actual insurance contract.
• Update plans when terms change: If the insurance company changes coverage or benefit limits mid-year, update the plan so future bills reflect the change.
• Service coverage is critical: Forgetting to add a service to the plan may cause billing errors; ensure all services your facility offers are linked to the correct plans.
• Test with a sample patient: Before rolling out a new plan widely, process a test invoice for a patient under that plan to confirm the cost-sharing and benefit calculations are correct.

---