Tpo

Last updated: 2026-03-29

Overview

The Insurance Integration (TPO/JoFotara) module connects your facility directly to health insurance providers. It allows you to electronically verify a patient's insurance coverage, request medical approvals (such as generating an E-Form), and submit final financial claims for payment without needing paper forms.

When Do I Use This?

  • Receptionists: When a patient arrives, to check if their insurance card is valid and active (Eligibility).
  • Doctors & Nurses: When prescribing a medication, lab test, or procedure that requires prior approval from the insurance company (Authorization/E-Form).
  • Accountants & Billing Staff: When a patient's visit is complete and you need to send the final bill to the insurance company for reimbursement (Claim Submission), or when generating an electronic invoice with a QR code.
  • Billing Staff: When an insurance company rejects a claim and you need to fix the error and send it back (Resubmission).

How To Use

1. Checking Eligibility & Requesting Approvals (E-Forms)

Use this process before providing services to ensure the insurance will cover the cost.

  1. Open the patient's visit record.
  2. Navigate to the Insurance / Approvals section.
  3. Verify the Member ID (Insurance Card Number) is entered correctly.
  4. Add the doctor's Diagnosis and the requested Activities (medications, tests, or services).
  5. Click Request Authorization or Check Eligibility.
  6. The system will instantly contact the insurance provider. If approved, you will receive a "Yes" result and an E-Form Number (Approval Code).

2. Submitting a Financial Claim

Use this process after services have been rendered to bill the insurance company.

  1. Go to the Billing → Claims screen.
  2. Review the patient's visit details, ensuring the total Gross amount, Net amount, and Patient Share are calculated correctly.
  3. Click Submit Claim.
  4. If successful, the system will generate an official Reference Number and may provide a QR Code link to print the patient's electronic invoice.

3. Resubmitting a Corrected Claim

If a claim is returned or denied due to an error (like missing documents):

  1. Find the rejected claim in the Claims screen.
  2. Click Resubmit.
  3. Attach any requested medical files in the Attachment field and add an explanatory note in the Comment field.
  4. Submit the correction.

Field Descriptions

Visit Information

Field Name Description
Member ID The patient's unique insurance card number.
Encounter Type The type of visit: Outpatient, Emergency, or Inpatient.
Diagnosis Code The official medical code (ICD-10) for the patient's illness or condition.

Services & Medications (Activities)

Field Name Description
Activity Type Categorizes what was provided (e.g., Drug, Medical Service, Lab Test).
Clinician The doctor or nurse who ordered or performed the service.
Quantity & Unit How much of the service/drug was provided.

Billing & Approvals

Field Name Description
Gross Amount The total, original price of the services before any insurance deductions.
Patient Share The exact amount the patient is required to pay out-of-pocket (copay/deductible).
Net Amount The final amount the insurance company is expected to pay the clinic.
Result Shows "Yes" if the insurance approved the service, or "No" if denied.
Payer ID (E-Form Number) The official approval transaction number provided by the insurance. You must save this for billing!
Tip: Always double-check the Patient Share amount shown after requesting authorization. Collect this amount from the patient at the front desk before they leave the facility!
Tip for Billing: If an authorization is denied ("Result: No"), look at the Comments or Error Text fields returned by the system. It will usually tell you exactly why (e.g., "Service not covered" or "Missing Diagnosis Code").
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