These instructions should be used when adding Private policy coverage for an Individual. You can add a Private policy from the Individual Profile, Case or Service File.

A Private policy is applicable when a client brings in private insurance whose parameters are specific to the Individual (i.e. authorizations, rates, dates and dollar limits are unique to that particular client and may not apply to anyone else with the same insurer).

Adding a Private Policy – Individual Profile

  1. Navigate to the client’s Individual Profile.

  2. Click on the Policy tab.

  3. Click Add.

  4. In the Funder field begin typing the name of the Funder and select from the Suggested Lookup options.

  5. From the Select a Policy list choose New Private Policy.

  6. Click Next.

  7. Complete the required Private Policy fields (details on each field below).

  8. Click Next.

  9. Complete the required Policy Member fields (details on each field below). Depending on your Penelope configuration you may also have the option to enter a Funder Department.

  10. Click Next.

  11. Complete the required Policy Coverage fields (details on each field below).

  12. Click Next.

  13. Select the Coverage Service Units and click the plus (+) icon to add the unit.

  14. Click Next.

  15. On the Private Policy Summary page confirm all details are correct and click Finish.

You will now need to add the policy to the applicable Service. If the Service has already been added you can do this by adding the policy to the Billing Sequence. Alternatively, add the Service and then add the policy to the Billing Sequence.

Adding a Private Policy – Case and Service File

  1. From the Case or Service File click Billing Information from the right-hand side menu.

  2. Select the Individual to be covered from the drop-down.

  3. Follow steps 4-15 as above.

Private Policy Field Details

Private Policy Fields

Policy Name – Enter a Policy Name.

Funder – Displays the name of the Funder.

Funder Collateral Contact – Choose the main contact in relation to this policy from the drop down. Leave blank if no collateral contacts have been entered for this Funder.

Policy Type – Choose a Policy Type.

Active – Ensure the Active box is selected.

Disable FFS – Click to prevent the client from being charged a FFS amount whenever there is a difference between the full charge and what is covered under the policy (including copay).

Disable Fee Override – Click to disable the ability to set a Service Unit Fee Override for any FFS amount charged to the client.

Disable SS – Click to disable the Sliding Scale applied to FFS amounts charged to the client.

Signed On – Select a date (Applicable to EDI billing: Selecting a date indicates that both the Assignment of Benefits Indicator and Release of Information Code values are set to yes).

Confirmed – Click to indicate the details of the Policy have been confirmed.

Accept Assignment – Click to indicate that Provider Accepts Assignment (Applicable to EDI billing: Indicates payment would be remitted to your agency rather than the client).

Type of Contract – Select the type of contact (Applicable to EAP billing: Inclusive means the Funder will not be billed for each service covered under the policy (i.e. they pay a set amount no matter the value of the actual services provided). Non Inclusive means the Funder will be billed for each service covered under the policy (opposite to Inclusive).

Notes – Type any notes about the Policy.

Policy Member Fields

Policy Name – Displays the Policy Name.

Active – Ensure the Active box is selected.

Relation – Displays the relationship of the client to the Policy Holder.

Member No. By – Choose how the Policy Member will be identified (Payor, NII or SSN).

Member No. – If applicable type the client’s Policy Member number.

Group No. – If applicable type the client’s Policy Group Member number.

Funder Department – If applicable enter the client’s Funder Department.

Notes – Type any notes about the Policy Member.

Policy Coverage Fields

Active – Ensure the Active box is selected.

Authorization No. – Enter the authorization number provided by the insurance company. If you don’t know this number you can leave this field blank.

Confirmed – Click the Confirmed box if the details of the policy have been confirmed.

No Show % – This is the percentage of the fee the Funder agrees to pay if the client is a no show. If no fee has been agreed leave at at zero.

Item Limit – If applicable specify the number of items included in the Coverage.

Date Limit (Start) – If applicable specify the start date of the Coverage.

Date Limit (End) – If applicable specify the end date of the Coverage.

Dollar Limit ($) – If applicable specify a dollar limit for the Coverage.

Notes – Type any notes about the Policy Coverage

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