Patient Cost Estimator Insurance Workflow

Insurance Workflow

1.  Payer, Provider and Service Location are required fields and must be entered to proceed with Cost Estimator.  Type into the field and select Search or select Search first to view a complete list, then select.

When initiating a Cost Estimator from the Patient Setup screen, certain fields may not be pre-filled.  Payer will load based on the patients primary payer in Patient Setup screen.

2. Add a line by Appt Type or Manual Entry

Add Line by Appt Type – Use this to add a service line for estimation by the type of appointment

This will search appointment types specific to your practice.  Associating CPTs with Appointment Types is required to utilize this feature

Add Line by Manual Entry – Use this to manually add a CPT for estimate 

This allows the user to enter a specific CPT code as well as Diagnosis code and modifier if needed.

Note required fields specified with the *. Depending on your CPT setup Unit, Charge per Unit and Allowed per Unit may populate with the CPT selection.   However, this screen allows manual entry as well as override.

If your company setting is set to use the "Payment Aggregated Allowed Amount" the Allowed Amount Usage will be defaulted to Aggregate and below it you will see Days to Aggregate which will display the default number of days but also allowing a manual override. You will also see a Records Used in Aggregate which will show how many payment records where used for the allowed amount payment aggregation. If your company setting is set to use the "Fee Schedule Allowed Amount" you will not see the additional aggregate fields.

Below is an example of both entries in a single estimate

Note the Action column which allows a line to be deleted or edited. 

3. Once line(s) have been added, choose whether you need to run a new eligibility check or manually enter benefits.

Check Eligibility - Opens Patient Eligibility screen to select insurance to run

Manual Entry -  Opens a screen allowing user to hand key items 

Note: If the eligibility response has multiple copays for a patient, you will receive a warning informing you that multiple copays were returned allowing the user to select the appropriate copay for the estimate from a drop-down.   

4. Choose whether you’ll need to use In Network benefits or Out of Network benefits

5. Coverage Category can be changed to run benefits for different care such as Durable Medical Equipment (DME), Allergy testing, etc.

5. Select Calculate to run the estimate 

6. Once estimate has been created and reviewed for accuracy, click Accept to lock and save this estimate.  If changes need to be made, make those then select Calculate before Accept.  

7. When Accept has been selected, a pop up message will alert the locking of this estimate.

Cancel will return to the previous screen for editing.  Confirm will lock this estimate.

8. The summary of the estimate will be visible on the lower part of the screen.  Click the print icon to print the summary.