Plan

Updated by Steven Garand

Plans are ways to get paid by a particular payer for example a POS plan.
Each payer needs at least one plan.
When a new Payer is added, a default Standard Retail Minus Plan is generated.
A plan can have an optional fee schedule. A fee schedule need at least one fee.
Plans with common fee schedules (or a common percent of a fee schedule) should reference a single fee schedule and not reproduce these fees in each plan. If a plan is close but has a few exceptions use the 'Fee Then Ref Other Payor' type described below.
If Type is set to Fee For Service, clear the Type % value. Any Type % value will be ignored in this case. If you need a percentage of a fee schedule, create a new plan with the base fee schedule, set this plan to reference the plan that has the base fee schedule and set the Type % to the desired percent off of the base fee schedule.

Plan Options

  1. Type and Type2 - Note: Type2 is only used if payer requires the lesser of 2 different ways of calculating the allowable. In this case Type2 (and Type2 % if applicable) would specify the second way to calculate the allowable.
    1. Reference Other Payer: Determines allowable by reference a percentage of an existing payer plan's fee schedule. Many plans can reference a single fee schedule in order to reduce the number of fee schedules that require updating.
    2. Fee For Service: Determines allowable by lookup in a fee schedule. Can contain a fee by code lookup, or a calculation based on other values such as retail minus a given percent.
    3. Cost Plus Extended: Determines allowable by cost including extended discounts. Adjusted up by Type % or Type2 %.
    4. Retail Minus: Determines allowable by retail (MSRP) adjusted down by Type % or Type2 %.
    5. Cost Minus Extended: Determines allowable by cost including extended discounts. Adjusted down by Type % or Type2 %.
    6. Retail Plus: Determines allowable by retail (MSRP) adjusted up by Type % or Type2 %.
    7. Base Cost Plus: Determines allowable by base cost only (excluding extended discounts). Adjusted up by Type % or Type2 %.
    8. Retail Minus x Bill Mult: Used to set allowable from bill amount. Determines allowable by retail (MSRP) adjusted down by Type % or Type2 % then multiplied by billing multiplier.
    9. MediCalFee: Determines allowable by lookup in a fee schedule. In addition, the bill amount is set to the lesser of the two allowables. This occurs for only for the primary payer plan on the order and only if Type2 values are entered in order to calculate the second allowable. Note: The MediCal fee schedule should be imported into the plan if this Type is used.
    10. Reference Other MediCal: Determines allowable by referencing a percentage of an existing MediCal (California Medicaid) payer plan. In addition, the bill amount is set to the lesser of the two allowables. This occurs for only for the primary payer plan on the order and only if Type2 values are entered in order to calculate the second allowable. Note: The MediCal fee schedule should be imported into the referenced plan if this Type is used.
    11. Fee Then Ref Other Payor: Used when referencing another payer is close but there are some exceptions. Allows the exceptions to be placed as fee for service items and are used first if matched. Codes that do not match the exceptions in the fee schedule use the referenced payer instead. Determines allowable by first trying to lookup a code match in a fee schedule. Can contain a fee by code lookup, or a calculation based on other values such as retail minus a given percent. If no code match is found in a fee schedule the referenced other payer is used to determine a percentage of the referenced allow value.
  2. Type % and Type2 %: Percent to change allowables calculated by the specified Type and Type 2 values.
  3. Reference Payer: Only used with a Type of Reference Other Payer or Fee Then Ref Other Payor. Determines the referenced fee schedule to use for this plan. Note: If this plan is Fee For Service and a fee item Type is Reference Other Payer, Reference Payer determines the referenced fee schedule.

Actions

  1. Add new plan *
  2. Delete plan **
  3. Update plan *
  4. View fees for plan
  5. Save plan changes
  6. Sort plans
  7. Move plan columns

* Row denied if 1.) Plan name is blank or 2.) plan name already exists for this payer, or 3.) Reference Other Payer specified in Type2, or 4.) or Type is Reference Other Payer and no Reference Payer specified, or 5. Reference Payer specified and Type is not Reference Other Payer or Fee for service) .

** Delete denied if payer plan used in orders or is a Reference Payer or if trying to delete all plans (must have at least one plan).

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