City and County of San Francisco Fiscal/Billing Workgroup

1. City and County of San FranciscoFiscal/Billing Workgroup July 22, 2009

2. Understanding of Benefit Plans

3. Disclaimer The following slides utilize examples of how the Benefit Plan option within Avatar functions. This is an elementary look at the process for educational purposes and does not follow any prescribed carrier policy. These examples are not necessarily recommended for customer file build. Please consult with your Implementer for file build recommendations for your agency.

4. Dictionary Build • Insurance Charge Categories: • Individual Therapy • Linked to service codes: • 341 Individual Therapy Office • 477 Individual Therapy 30 mins • Assessment • Linked to service codes: • 331 Assessment & Evaluation • 335 Assessment Screening YGC • Case Management • Linked to service codes • 390 Case Management Kids CFT • 391 Case Management & Brokerage Prior to completion of the Benefit Plan build, two multiple select dictionaries that the option utilizes require development – Insurance Charge Categories Practitioner Categories for Coverage Insurance Charge Categories are linked to Service Codes. This identifies groups of services covered by insurance carriers. Assume if multiple types of services (Service Codes) were usually covered by the same coverage option by insurance carriers, then these would be grouped together. The column at the right is the Insurance Charge Categories for the examples to follow.

5. Dictionary Build (con’t) • Practitioner Category for Coverage: • Licensed Clinical Social Worker • Linked to practitioner: • Sally Jones • Marriage Family Therapist • Linked to practitioner: • Larry Smith • Case Manager • Linked to practitioner: • Casey Thompson • Psychiatrist • Linked to practitioner: • John Gibson Practitioner Categories for Coverage is linked to Practitioner Enrollment. This identifies groups of practitioners covered by insurance carriers. Assume if multiple practitioner types were usually covered by the same coverage option by insurance carriers, then these would be grouped together. The column at the right is the Practitioner Categories for Coverage for the examples to follow. Note: Practitioner Categories for Coverage can also be used in the Appointment Search option but will be covered in a separate demonstration.

6. Option File Build • Benefit Plan: • Medicare • Linked to Guarantor: • Medicare • Linked to Insurance Charge Categories: • Individual Therapy • Assessment • Linked to Practitioners Category for Coverage: • Licensed Clinical Social Worker • Psychiatrist • Benefit Plan: • Commercial • Linked to Guarantor: • Aetna • Blue Cross • Linked to Insurance Charge Categories: • Individual Therapy • Assessment • Linked to Practitioners Category for Coverage: • Licensed Clinical Social Worker • Marriage Family Therapist • Psychiatrist • Benefit Plan: • Self Pay • Linked to Guarantor: • UMDAP • Linked to Insurance Charge Categories: • Individual Therapy • Assessment • Case Management • Linked to Practitioners Category for Coverage: • Licensed Clinical Social Worker • Marriage Family Therapist • Case Manager • Psychiatrist The Benefit Plan is the basic defined plan and level of coverage for a guarantor. The plan contains the categories which direct the system to appropriate Service Codes that are covered by the plan. Since the Benefit Plan is associated with the client’s guarantor, the system is able to establish whether the guarantor will pay for the Service Code. The column at the right is the Benefit Plans and their associated Guarantors for the examples to follow.

7. Benefit Plan Option – Medicare Example Path: System Maintenance → System Definition → Benefit Plans Tab: Benefit Plan Level Page 1 Tab: Benefit Plan Level Page 2 Note: Insurance Charge Category Assessment checked but not ADP services or Collateral Note: Practitioner Category for Coverage Licensed Clinical Social Worker checked but not Marriage Family Therapist

8. For the following examples… These items remain constant: • Client • Guarantors assigned to the client in Financial Eligibility These Items to pay particular attention to: • Service code • Practitioner of service

9. Example: Peter Parker – client • Financial Eligibility Information: • Primary Guarantor = • Medicare • Benefit Plan = Medicare • Secondary Guarantor = • Blue Cross • Benefit Plan = Commercial • Tertiary Guarantor = • UMDAP • Benefit Plan = Self Pay • Service 1 (7/1/2008): • 331 Assessment & Evaluation • Insurance Charge Category = Assessment • Practitioner John Gibson MD • Practitioner Category for Coverage = Psychiatrist The service is posted and the system distributes the liability based on the benefit plan rules assigned to the guarantor in order of position in Financial Eligibility. Option Financial Eligibility for client Check Primary - Medicare Benefit Plan covers Insurance Charge Category? Note: Order of Guarantors Check Primary - Medicare Benefit Plan covers Practitioner Category for Coverage? MEDICARE IS BILLED

10. Client Ledger: Service 1

11. Example: Peter Parker – client • Financial Eligibility Information: • Primary Guarantor = • Medicare • Benefit Plan = Medicare • Secondary Guarantor = • Blue Cross • Benefit Plan = Commercial • Tertiary Guarantor = • UMDAP • Benefit Plan = Self Pay • Service 2 (7/3/2008): • 341 Individual Therapy Office • Insurance Charge Category = Individual Therapy • Practitioner Larry Smith • Practitioner Category for Coverage = Marriage Family Therapist The service is posted and the system distributes the liability based on the benefit plan rules assigned to the guarantor in order of position in Financial Eligibility. Check Primary - Medicare Benefit Plan covers Insurance Charge Category? Check Primary - Medicare Benefit Plan covers Practitioner Category for Coverage? Medicare will be skipped as service does not meet plan coverage rules

12. Example: Peter Parker – client • Financial Eligibility Information: • Primary Guarantor = • Medicare • Benefit Plan = Medicare • Secondary Guarantor = • Blue Cross • Benefit Plan = Commercial • Tertiary Guarantor = • UMDAP • Benefit Plan = Self Pay • Service 2 (7/3/2009): • 341 Individual Therapy Office • Insurance Charge Category = Individual Therapy • Practitioner Larry Smith • Practitioner Category for Coverage = Marriage Family Therapist Check Secondary - Commercial Benefit Plan covers Insurance Charge Category? Check Secondary - Commercial Benefit Plan covers Practitioner Category for Coverage? MEDICARE IS SKIPPED BLUE CROSS IS BILLED

13. Client Ledger: Service 1 & 2

14. Example: Peter Parker – client • Financial Eligibility Information: • Primary Guarantor = • Medicare • Benefit Plan = Medicare • Secondary Guarantor = • Blue Cross • Benefit Plan = Commercial • Tertiary Guarantor = • UMDAP • Benefit Plan = Self Pay • Service 3 (7/20/2008): • 391 Case Management & Brokerage • Insurance Charge Category = Case Management • Practitioner Casey Thompson • Practitioner Category for Coverage = Case Manager The service is posted and the system distributes the liability based on the benefit plan rules assigned to the guarantor in order of position in Financial Eligibility. Check Primary - Medicare Benefit Plan covers Insurance Charge Category? Check Primary - Medicare Benefit Plan covers Practitioner Category for Coverage? Medicare will be skipped as service does not meet plan coverage rules

15. Example: Peter Parker – client • Service 3 (7/05/2008): • 391 Case Management & Brokerage • Insurance Charge Category = Case Management • Practitioner Casey Thompson • Practitioner Category for Coverage = Case Manager • Financial Eligibility Information: • Primary Guarantor = • Medicare • Benefit Plan = Medicare • Secondary Guarantor = • Blue Cross • Benefit Plan = Commercial • Tertiary Guarantor = • UMDAP • Benefit Plan = Self Pay Check Secondary - Commercial Benefit Plan covers Insurance Charge Category? Check Secondary - Commercial Benefit Plan covers Practitioner Category for Coverage? Medicare and Blue Cross will be skipped as service does not meet plans coverage rules

16. Example: Peter Parker – client • Service 3 (7/05/2008): • 391 Case Management & Brokerage • Insurance Charge Category = Case Management • Practitioner Casey Thompson • Practitioner Category for Coverage = Case Manager • Financial Eligibility Information: • Primary Guarantor = • Medicare • Benefit Plan = Medicare • Secondary Guarantor = • Blue Cross • Benefit Plan = Commercial • Tertiary Guarantor = • UMDAP • Benefit Plan = Self Pay Check Tertiary - Self Pay Benefit Plan covers Insurance Charge Category? Check Tertiary - Self Pay Benefit Plan covers Practitioner Category for Coverage? MEDICARE AND BLUE CROSS SKIPPED SELF PAY IS BILLED

17. Client Ledger: Service 1, 2 & 3

18. What if? • Peter Parker, instead, had Case Management Services with John Gibson MD. Where would the liability go? • Medicare? • NO! • Why? • Medicare Benefit Plan does cover the Practitioner Category but not the Insurance Charge Category. • Blue Cross? • NO! • Why? • Commercial Benefit Plan does cover the Practitioner Category but not the Insurance Charge Category. • UMDAP? • YES! • Why? • Self Pay Benefit Plan does cover both the Practitioner and Insurance Charge Categories.

19. What if? • Peter Parker’s coverage changed from Blue Cross to Aetna with the same Benefit Plan would Case Management & Brokerage (391) Service Code with John Gibson MD bill to Aetna? • Aetna? • NO! • Why? • Aetna is assigned the to the same Benefit Plan “Commercial” as Blue Cross is. • Commercial Benefit Plan does cover the Practitioner Category but not the Insurance Charge Category.

20. Review – Benefit Plan Option Build • Benefit Plans can be assigned to one or more guarantors. • Benefit Plans are defined by the majority of coverage plan rules. Such as: • Deductibles • Co-Pays • Insurance Charge Categories (Service Codes) • Practitioner Categories for Coverage • Think - Capture 80% of the typical coverage rules and the remaining 20% can be customized.

21. Benefit Plans Additional Considerations • Benefit Plans can be customized for the client in Financial Eligibility. • Use with caution as customized client Benefit Plans cannot be updated through the Benefit Plan Update option. • Use customization for plans that apply to less than 20% of client base (outliers). • Benefit Plans can be updated as coverage rules change through Benefit Plan Update option.

22. Thank you for your participation • Review the User Guide • Test your system • Consult with your Implementer