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

A Public policy always includes a set of services however the actual parameters of the coverage may vary depending on the Individual (i.e. the number of authorized Service Units, date and dollar limits may vary depending on the Individual).

It’s important to note that the Service Unit dollar value will not vary between policies and that Medicaid/Medicare authorizations can be handled using this type of policy.

Adding a Public 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 the required Public Policy template. Public policies are denoted by the Public prefix.

  6. Click Next.

  7. Complete the required Public 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.

  14. Click Next.

  15. On the Public 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.

Public Policy Field Details

Public 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 on leave 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

Adding a Public 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.


ADD A PUBLIC POLICY

THE BASICS

This type of policy offers a set of services under specific rates but the actual parameters of coverage may vary from individual to individual. For example, the number of authorized service units, date and dollar limits may vary for each individual under the policy. Medicaid and Medicare authorizations can be handled using this type of policy.

STEP 1

On the Funder Profile screen, open the Public Policy Setup sidebar and click Add.

STEP 2

Enter a Policy Name. This is the name workers will select when associating the policy with each client. If you are using the CMS-1500 form to submit paper claims (in the U.S. only), this will populate the Plan Name field in Box 11c.

STEP 3

Check the Active box to make the policy active in Penelope.

STEP 4

Enter a Start Date. This is the earliest possible date a client’s policy might start. You do not need to enter an end date until such time as your agency no longer accepts this policy. Remember you are adding the ‘master policy’ here and not a policy for a specific client.

STEP 5

Enter a Policy Number provided by the funder. If no such number exists or you do not know it, you can leave this field blank.

STEP 6

Choose a category from the drop-down. This list is configured by your system administrator.

STEP 7

Choose a Policy Type. This list is also configured by your system administrator.

STEP 8

Disable FFS means ‘Disable Fee for Service.’ Most likely, this will be checked – if it is not, then Penelope will look to charge the client a FFS amount wherever there is a difference between the full charge for a service unit in the system and whatever the coverage rates (including co-pay) are in a given policy.

STEP 9

No Show Percentage – if the funder agrees to pay a percentage of the fee even if a client is a no show, then enter that percentage here. Otherwise, leave at zero.

STEP 10

From the Service Unit drop-down, select an item covered by this policy. For each item, add the coverage rate and co-pay. If there is no co-pay, enter 0 in the co-pay box.

STEP 11

SSQ Rate means subsequent payer rate. If the funder agrees to be a subsequent payer, check the SSQ Rate box and enter the appropriate rate(s) here. If not, leave unchecked. Click the ‘plus’ button to add each item to the coverage. Continue adding items until you are finished. Click next.

STEP 12

The Public Policy Setup Summary page allows you to review what you entered when setting up the policy. To make any changes, click the back button at the bottom of the screen and update the appropriate fields (you will not lose any information you have already entered). If you are finished, click the Finish button at the bottom of the screen.

The public policy is created.

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