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Insurance Plan Levels Section - Cal-PM

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Define information that will populate financial eligibility forms, and will be used in the liability distribution process.

In financial eligibility forms, the benefit plan information defined here can be edited to meet a client’s requirements.

  1. In the Insurance Plan Levels table click Add New Item.

  2. The Level Number field shows the next available level number.

  3. In the Level Start Date field, enter the benefit plan level start date. Services are applied after this date.

  4. In the Level End Date field, enter the benefit plan level end date. Services are applied after this date. If no benefit levels are available, liability is not applied for the guarantor.

  5. In the Deductible Type field, select the type of deductible. Required if a deductible applies to the benefit plan level.

  6. In the Deductible Amount field, enter the deductible amount. Required if a deductible applies to the benefit plan level.

  7. In the Per Diem Rate field, enter the per diem rate. Required for contract plans.

  8. In the Per Diem Percentage field, enter the per diem percentage charge covered in the benefit plan level. Required for contract plans.

  9. In the Covered Charge Categories field, select the insurance charge categories to be included in the benefit plan level.

  10. In the Insurance Dollar Limit field, enter the total dollar amount.

  11. In the Insurance Dollar Limit Per Day field, enter the maximum daily dollar amount covered. Used for non-contract plans.

     During liability distribution, if the amount in any of the following fields is exceeded, the next benefit plan level will be evaluated.

  1. In the Maximum Covered Days field, enter the maximum number of service days covered. Used for non-contract plans.

  2. In the Maximum Covered Partial Days field, enter the maximum number of days covered. This value is the maximum number of applied partial hospitalization days.

  3. In the Maximum Covered Ancillary Charges field, enter the maximum dollar amount for ancillary charges. This value is the service fee applied for ancillary/other charges.

  4. In the Maximum Covered Visits field, enter the maximum number of service visits. This value is the maximum number of services defined as visits (Service Codes form).

  5. In the Monthly Maximum Responsibility field, enter the maximum dollar amount per month.

  6. In the Maximum Units Per Day field, enter the maximum number of service units for a single day. This value is the number of service units applied to the benefit plan level in one day. Used for non-contract plans.

  7. In the Insurance Dollar Limit RB Per Day field, enter the room and board maximum dollar per day amount charged to the guarantor for this plan level. If the amount is exceeded, the next plan level will be evaluated for the remainder.

  8. In the Percentage of Coverage field, enter the percentage of the total charge covered. The service fee is multiplied by this percentage for the amount of charge covered by the guarantor. Any remainder is evaluated by the next guarantor. Used for non-contract plans.

  9. In the Maximum Amount Per Service field, enter the maximum service charge amount. Any additional remaining liability is evaluated by the next guarantor. Used for non-contract plans.

  10. In the Practitioner Categories Necessary For Coverage field, select the practitioner categories authorized to provide services. If a practitioner is associated with the charge categories, the service charge will be evaluated by the next benefit plan level.

  11. Click Submit.