Manage Benefit Plans

A benefit plan, which requires a subgroup, identifies the benefits an individual receives as the result of their association with the subgroup. Claims, Disability, Eligibility, and COBRA are affected by Benefit Plans.

Go to: Home > Codes and Criteria > Fund Relationships > Benefit Plans

The Benefit Plans screen contains three (3) tabs — General Information, Claims Schedules, and Disability Schedules.

Benefit Plans Field Descriptions

* indicates a required field

Field	Description
General Information tab
*Benefit Plan Code	The name of the benefit plan.
Description	A brief description of the plan.
*Plan Type	A code identifying the plan and its priority. For example, Medical, Dental, etc. See Manage Plan Types for more information.
*Begin Date	The initial effective date for the benefit plan.
End Date	The termination date for the benefit plan.
Fund	The fund linked to the benefit plan. Note: Enter the fund if using Premium Billing to update eligibility.
Lag Days	The number of days after the hire date that the eligibility plan begins. Enter up to three (3) digits. Note: This field is only used with Single Employer Eligibility - Version 4.
Termination Lag	Determines when benefits will terminate for a member who loses eligibility: `Blank`—Benefits terminate at the end of the calculation. `T`—Benefits terminate on the member's termination date, which is tracked in Member Status Dates. `M`—Benefits terminate at the end of the month. `Numeric value`—The number of days after the member's termination date when benefits terminate. For example, 15 would indicate that benefits terminate 15 days after the termination date. `D#`—The number identifies a date of the month, for example, D15. If the employee loses eligibility before that date, benefits terminate on the day eligibility is lost; if the employee loses eligibility after that date benefits terminate at the end of the month. For example, 15 would indicate that an employee who lost eligibility on the 4th of a month would terminate on the 4th. An employee who lost eligibility on the 18th of a month would terminate at the end of that month. Note: This field is only used with Eligibility Version 6 and is linked to Member Status Codes with a type of `E`.
First Day	Indicates if eligibility is effective on the first day of the month. `Yes`—Plan eligibility is always effective on the first of a month. `No`—Plan eligibility isn't effective on the first of a month. Note: This field is only used with Single Employer Eligibility - Version 4.
Ins. Line Code Value	A predefined HIPAA insurance code identifying an insurance product. Associate your benefit plan code with the predefined HIPAA insurance line code when needed for HIPAA transmissions. The HIPAA insurance line codes are: `AG`—Preventative Care/Wellness `AH`—24 Hour Care `AJ`—Medicare Risk `AK`—Mental Health `DCP`—Dental Capitation (Dental Managed Care Organization) `DEN`—Dental `EPO`—Exclusive Provider Organization `FAC`—Facility `HE`—Hearing `HLT`—Health (includes hospital and professional) `HMO`—Health Maintenance Organization `LTC`—Long-Term Care `LTD`—Long-Term Disability `MM`—Major Medical `MOD`—Mail Order Drug `PDG`—Prescription Drug `POS`—Point of Service `PPO`—Preferred Provider Organization `PRA`—Practitioners `STD`—Short-Term Disability `UR`—Utilization Review `VIS`—Vision `Blank`—If blank, the benefit code will be transmitted for this field.
# of Months to Check Pre-Existing	The number of months between the member's eligibility date and a claim's incurred date in which a user processing a claim will be prompted for pre-existing conditions. Enter up to three (3) digits.
Coverages Allowed	The coverage types allowed under this benefit plan.
Use Member / DEP PPO	Determines if the member/dependent PPO is used for the benefit plan: `Yes`—PPO will be used. `No`—PPO won't be used.
Use PPO if Other Ins is Prepaid	Determines if a PPO will be used if other insurance prepays: `Yes` or `Blank`—Yes, a PPO will be used if other insurance prepays (the default). `No`—No, a PPO won't be used if other insurance prepays.
Use PPO if Medicare Prepaid	Determines if a PPO will be used if Medicare prepays. `Yes` or `Blank`—Yes, a PPO will be used if Medicare prepays. `No`—No, a PPO won't be used if Medicare prepays. Note: If set to `No` and the claim has an amount in `Total Medicare Prepaid`, none of the line items will use a PPO. If the prepay is on the line item, only the line item with the prepay doesn't use the PPO.
Alternate Plan Types	The alternate plan types allowed in this benefit plan.
Proration Method	Indicates the prorated method that will be applied. For premium billing, the `Proration Method` for the billing account should be `BPLAN`: `30D`—Prorated by day based on 30 days in every month. `CO`—Full premium, billed based on a cut-off day number within the period. Enter the cut-off day in `# of Days`. For example, if effective on or before the cut-off day or terminated on or after the cut-off day, full premium is billed. If effective after the cut-off day or terminated before the cut-off day, no premium is billed. `COH`—Half premium, billed based on a cut-off day number within period. Enter the cut-off day in `# of Days`. For example, if effective on or before the cut-off day or terminated on or after the cut-off day, full premium is billed. If effective after the cut-off day or terminated before the cut-off day, half premium is billed. `DF`—Prorated daily based on starting date only; full premium if terminated. `F`—Full premium billed if covered one or more days in the period. `F1`—No premium billed if not covered from the first day of the period or if covered from the 1st day of the period and terminated in the same month. Prorated daily if covered the first day of the period and terminated before the end of the period. `FXB`—Full premium billed across benefit plans. `N` or `Blank`—None.
# of Days	The number of cut-off days for the `Proration Method` of `CO` or `COH`.
Age Calculation Method	Indicates the Benefit Plan age calculation to be used for CVB rate calculation. For this to be considered, the CVB `Age Calculation Method` should be `BP`. `Blank`—None `BP`—Billing Period `BPL`—Beginning of Plan Year `BS`—Billing Year Semi-annual `BY`—Billing Year `CP`—Current Period `CY`—Current Year `ECY`—End of Current Year `EPL`—End of Plan Year `M`—Modified
Arrears End Date Method	Determines how the CVB calculation adjusts eligibility for those coverage periods in arrears: `Blank`—None, no arrears adjustment done on calculated eligibility. `A`—Day before the arrears begin (the default). `AD`—Day before the arrears begin date plus the number of grace days.
Grace Days	The number of grace days for the `Arrears End Date Method` of `AD`.
Arrears ERC Method	Determines how the arrears end reason code (ERC) will be constructed for eligibility. `Blank`—None. `AR`—Literal string "AR" will be used as the ERC. `ARC`—The arrears reason code used as the ERC. `ARCm`—The arrears reason code and `M` number of consecutive coverage periods in dispute; enter a numeric value when selected (for example, LT2 for late term, 2 months in arrears). `ARM`—Literal string with `M` number of coverage periods disputed.
# of Cvg Periods	The number of coverage periods for the `Arrears ERC Method` of `AR` or `ARC`.
Use Referrals	Denotes if referral tracking is used in this benefit plan: `Yes`—Uses referral tracking. `No` or `Blank`—Doesn't use referral tracking.
Display Type	Determines when a referral will be displayed in the Referral window: `A`—Always. `R`—Only if the `Referred to TaxID` and `Referred to Service Provider` match the Tax ID and the line item Service provider on the claim. `T`—Only if the `Referred to TaxID` matches the Tax ID on the claim.
Days to Display	Designates the number of days before or after the claim date of service to display the list of referrals for linking in claims entry and processing. Enter up to five (5) digits. Note: If this field is set to 30 and the referral starts 10/31 and ends 11/30, then it would display for claims with dates 10/1 through 12/30. If this field is 99999, then it display all referrals.
Referral Type to Match	The referral type to match.
Claims Schedules tab
Benefit Plan Description	The description of the benefit plan defined on the `General Information` tab.
Schedule Link Effective Dates	The effective date range for the schedule. The current range displays by default.
*Schedule	The default schedule for the claims in this benefit plan.
Procedure Source RV Code	The procedure code for the relative value. This code will override the schedule default code if no procedure source code is found on the benefit code level.
Procedure Source UCR Code	The procedure code for the UCR. This code will override the schedule default code if no procedure source code is found on the benefit code level.
Ref Flag	Determines if referrals are required to use this schedule: `A`—Approved referrals. The schedule will only be used if the claim has an approved referral. `D`—Denied referrals. The schedule will only be used if the claim has a denied referral. `Blank`—Referrals don't matter for this benefit plan. Note: Multiple entries could exist here if different schedules are used for PCP claims and referral claims.
M/O/D Flag	Medicare / Other insurance / Dual COB flag. `R`—Required. Use this schedule if the claim has a Medicare or other insurance prepayment. If the claim has no Medicare or other insurance prepayment, select from other non-flagged schedules. `D`—Dual COB (Coordination of Benefits) coverage. `Blank`—All schedules are valid. Note: Only one `R` or `D` type is allowed per effective date schedule link.
*PPO	The PPOs that can be used in this benefit plan.
*Schedule	The schedule the PPO uses.
Procedure Source RV Code	The procedure code for the relative value. If the PPO is used for processing a claim, the pricing information here will override the schedule defaults.
Procedure Source UCR Code	The procedure code for the UCR. If the PPO is used for processing a claim, the pricing information here will override the schedule defaults.
Fee Percent	The fee percentage. This specifies the administrative fee for the internal PPO. Enter a number between 0 to 100 which represents the percentage.
Fee Flag	The fee's billing method: `Blank`—Administrative fee will be taken automatically on front end. `B`—Backend Billing. Administrative fee will be billed on the back end.
PCP	The PCP requirements for using the aligned schedule and other aligned information: `Y`—Line item service provider must match the claimant's PCP service provider to use this schedule. `N`—Line item service provider must not match the claimant's PCP service provider to use this schedule. `YT`—Billing provider must match the claimant's PCP tax ID to use this schedule. `NT`—Billing provider must not match the claimant's PCP tax ID to use this schedule. `Blank`—PCP relationship doesn't matter.
Ref Flag	Determines if referrals are required to use this schedule: `A`—Approved referrals. The schedule is only used if the claim has an approved referral. `D`—Denied referrals. The schedule is only used if the claim has a denied referral. `Blank`—No referrals. Note: Multiple entries could exist if different schedules are used for PCP claims and referral claims.
M/O/D Flag	Medicare / Other insurance / Dual COB flag. `R`—Required. Use this schedule if the claim has a Medicare or other insurance prepayment. If the claim has no Medicare or other insurance prepayment, select from other non-flagged schedules. `D`—Dual COB (Coordination of Benefits) coverage. `Blank`—All schedules are valid. Note: Only one `R` or `D` type is allowed per effective date schedule link.
Disability Schedules tab
From Date	The from date for the disability schedule.
Through Date	The through date for the disability schedule.
Disability Schedule	The disability schedule.
Description	A description of the disability schedule.

Add a benefit plan

General Information tab

On this tab, define the overall settings for the benefit plan, including coverages, referrals, alternate plan types, and coverage billing and PPO information.

Click .
Enter a name for the benefit plan code and click .

Enter a description for the benefit plan code.
Select the Plan Type.
Select the plan's Begin Date. If applicable, select the End Date.
Select the Fund linked to the benefit plan.
At Lag Days, enter the number of days after the hire date that the eligibility plan begins.
Choose the Termination Lag to determine when benefits terminate for a member who loses eligibility.
At First Day, choose Yes if plan eligibility is effective on the first day of the month or choose No if it isn't effective on the first day.
Select the Insurance Line Code Value to send in HIPAA transmissions.
At # of Months to Check for Pre-Existing, enter the number of months between the member's eligibility date and claim incur date for which a user processing claims will be prompted for pre-existing conditions.

In the Coverages Allowed table, define the coverages that are allowed under the benefit plan. You must add at least one coverage to save the benefit plan.

Click to enter a coverage code. The description of the coverage code automatically displays. (See Manage Coverages for more information.) Note that you can't add a duplicate coverage code.
If you need to delete a coverage code, select the row you want to delete from the table and click .

In PPO Details, select how PPOs work for this benefit plan.

In Use Member/Dep PPO, choose Yes if a PPO is used or No if a PPO isn't used.
In Use PPO if Other Ins is Prepaid, choose Yes if a PPO is used when other insurance prepays or No if the PPO won't be used if other insurance prepays.
In Use PPO If Medicare Prepaid, choose Yes if a PPO is used when Medicare prepays or No if the PPO won't be used if Medicare prepays.

In the Alternate Plan Types table, define the different plan types that are allowed to be used with the benefit plan. For example, a plan type of MED may be a comprehensive plan including dental and/or vision benefits. (See Manage Plan Types for more information.)

Click to enter a plan type.
Enter the plan type and press the search icon or Enter to search for the plan type. If found, the Description will display. Note that you can't add a duplicate plan type.
If the plan type you entered doesn't exist, a red border displays around the type. Validate the name of the type you want to enter in Manage Plan Types.

If you need to delete an alternate plan type, select the row you want to delete from the table and click .

In the Coverage Billing section, add the information needed for coverage billing options.

Choose the Proration Method. If you selected CO or COH, enter the # of Days.
Choose the Age Calculation Method.
Choose the Arrears End Date Method. If you selected AD, enter the number of Grace Days.
Choose the Arrears ERC Method. If you selected AR or ARC, enter the # of Cvg Periods.

In the Referrals section, determine if referrals are required for this benefit plan.

At Use Referrals, choose Yes if the benefit plan uses referral tracking or No if it doesn't.
Choose when a referral displays in the Referral window in Display Type.
At Days to Display, enter the number of days before or after the claim date of service to display the list of referrals for linking in claims entry and processing.

In the Referral Type to Match table, select the referral types to match.
- Click to enter a referral type. The description of the referral type automatically displays. Note that you can't add a duplicate referral type.
- If you need to delete a referral type, select the row you want to delete from the table and click .
After reviewing the information, click to save.

Claims Schedules tab

This tab contains the claim schedule information for you to manage the default claim and PPO schedules.

The Benefit Plan Description and the Schedule Links Effective Dates initially display when you navigate to this tab. The current effective date period displays by default, but you can change the effective date range to view other schedule data for different effective periods.

There are two tables to update: Default Schedule and PPO Schedules:

In the Default Schedule table, add the claim schedule codes that are appropriate for the selected effective dates under this benefit plan.
In the PPO Schedule table, add each PPO that can be used for the selected effective dates under this benefit plan.

You can Export from table or Print from table from the table options menu .

Select the Claims Schedules tab.
If you want to change the Schedule Link Effective Date range, click .

In the window, click to enter the From and Thru Dates.
At Use First Valid PPO, choose Yes if the first valid PPO will be selected or No if the PPOs aren't prioritized. This field is used for providers who belong to multiple PPOs. If Yes, the system automatically chooses the first PPO found in the benefit plan hierarchy when processing claims. If any of the valid PPOs are marked as pre-priced, the operator will have to choose.
You can also click to copy a previously entered effective date range. Select the From and Thru Dates and the Use First Valid PPO option for the copied dates.
A Detail Refno is assigned to the date range.
If you need to delete a date range, select the row you want to delete from the table and click .

At the message, click to delete the effective date range or to return to the window without deleting.
After entering the dates, click or to cancel.

To update the Default Schedule table, click .

Select the Schedule.
Choose the Procedure Source RV Code and Procedure Source UCR Code.
At Ref Flag, choose A if this schedule will only be used if the claim has an approved referral, D for a denied referral, or leave this field blank if no referrals are needed for this benefit plan.
At M/O/D Flag (Medicare/Other Insurance/Dual COB), select R for required if the claim has a Medicare or other insurance prepayment or D for dual COB coverage. If the claim has no Medicare or other insurance prepayment, select from other non-flagged schedules. Leave this field blank if all schedules are valid.
Click to update the table.

If you need to delete a schedule you added, select the row from the table and click .

To update the PPO Schedules table, click .

Select the PPO and Schedule.
Choose the Procedure Source RV Code and Procedure Source UCR Code.
At Fee Percent, enter the percentage for the internal PPO's administrative fee.
Leave the Fee Flag blank if the administrative fee should be billed on the back end or select B if this fee with be taken automatically on the front end.
Choose the PCP. This determines PCP requirements for using the aligned schedule and other aligned information.
At Ref Flag, choose A if this schedule will only be used if the claim has an approved referral, D for a denied referral, or leave this field blank if no referrals are needed for this benefit plan.
At M/O/D Flag (Medicare/Other Insurance/Dual COB), select R for required if the claim has a Medicare or other insurance prepayment or D for dual COB coverage. If the claim has no Medicare or other insurance prepayment, select from other non-flagged schedules. Leave this field blank if all schedules are valid.
Click to update the table.

If you need to delete a schedule you added, select the row from the table and click .

Click to save.

Disability Schedules tab

On this tab, select the disability schedules to link to the benefit plan.

Select the Disability Schedules tab.
To update the Disability Schedule Links table, click .
- Select the From and Through Dates. You must select a Through Date if the From Date is in the future.
- Choose the Disability Schedule.
- Click to update the table. The disability schedule's description displays automatically.
- If you need to delete a disability schedule you added, select the row from the table and click .
Click to save.

Edit a benefit plan

Select the benefit plan to edit from the Benefit Plan list.
Edit any of the information on the three tabs.

After verifying your changes, click to save.

Delete a benefit plan

Select the benefit plan to delete from the Benefit Plan list.

Click .
At the message, click to delete the benefit plan or click to return to the Benefit Plan screen.

If you selected , the benefit plan is deleted from the list.