Insurance

Last updated: 2026-03-29

Insurance Management

The Insurance module helps you manage insurance companies, their specific plans (policies), and your patients' active coverages. It tracks what insurance a patient holds and determines how much they—and their insurance company—should pay for medical services, products, or procedures based on copays and deductibles.

When Do I Use This?

  • When partnering with a new health insurance company and you need to add them to your system.
  • When an insurance company releases a new health plan (policy) with specific pricing rules.
  • When setting up copayments, deductibles, and agreed prices for specific hospital services.
  • When a patient visits the clinic and you need to register their insurance card to their file.

How To Use

1. Creating a New Insurer (Insurance Company)

Before you can assign insurance to a patient, the insurance company must exist in the system.

  1. Go to Insurance → Insurer from the main menu.
  2. Click + New.
  3. Select the company's Party profile (this links their contact information).
  4. Enter their License No and select their Type.
  5. Click Save.

2. Creating a Policy (Insurance Plan)

Insurers often have multiple plans (e.g., "Silver Plan", "Gold Plan"). You must create these under the Insurer.

  1. Go to Insurance → Policy.
  2. Click + New.
  3. Enter the Name of the plan and select the Insurer it belongs to.
  4. Click Save.

3. Setting up Policy Pricing & Rules (Policy Lines)

Once a Policy is created, you must define the pricing rules for the services you provide.

  1. Open the specific Policy you just created.
  2. Scroll down to the Policy Lines section and click + Add.
  3. Select either a Product Category (e.g., all "Laboratory Tests") OR a specific Product (e.g., "Complete Blood Count").
  4. Enter the Scheduled Price (the amount the insurer agrees to pay), the Copayment, and the Deductable.
  5. Click Save.

4. Assigning Patient Coverage

Link a patient to an active insurance policy so the billing system can automatically apply the correct pricing.

  1. Go to Insurance → Coverage.
  2. Click + New.
  3. Select the Patient and their specific Policy.
  4. Enter their Member ID exactly as it appears on their insurance card.
  5. Ensure the Active box is checked, then click Save.

Field Descriptions

Insurer & Insurer Type Fields

Field Name Description
Party The core company profile (address, phone numbers) associated with this insurer.
License No The official business or healthcare license number of the insurance company.
Parent Used if this insurer is a branch or subsidiary of a larger parent insurance company.
Type Categorizes the insurer (e.g., HMO, PPO, Government). Types have a Name, Code, and Color.

Policy & Policy Line Fields

Field Name Description
Name (Policy) The official name of the health plan (e.g., "Premium Corporate Health").
Insurer The insurance company that provides this plan.
Product Category Applies pricing rules to an entire group of services (e.g., all Consultations).
Product Applies pricing rules to one specific service or item (e.g., MRI Scan). Overrides category rules.
Scheduled Price The specific price the insurance company has agreed to pay the clinic for this item/category.
Copayment The fixed amount the patient must pay out-of-pocket for this specific service.
Deductable The amount the patient pays before the insurance coverage begins to pay.

Patient Coverage Fields

Field Name Description
Policy The specific insurance plan the patient is enrolled in.
Patient The patient who holds the insurance.
Member ID The patient's unique identification number provided by the insurance company.
Active Indicates if the insurance is currently valid. Uncheck this if the patient's plan expires or changes.
Note Any special instructions or remarks regarding the patient's coverage.
Tip: Always double-check the Active status on a patient's Coverage before billing. If a patient changes jobs or insurance plans, uncheck "Active" on their old coverage rather than deleting it, to preserve historical billing records.
Tip: When setting up Policy Lines, you don't need to add every single product individually! Set the general rules using Product Categories first, and only use specific Products for exceptions.
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