Service Coverage Grouping (introduced in version 126.96.36.199) allows users to prioritize Services that are covered by an Individual’s policy over those that are not.
When a user is adding a new Service File, Case Services will be grouped under the Covered list if at least one Case member has policy coverage for at least one of the Service Units. Otherwise, the Case Services will be grouped under the Other list.
Additionally, when a Service Unit is added to an Event, the user will get a confirmation message if that Service Unit is not covered.
Enable Service Coverage Grouping
To enable the Service Coverage Grouping feature, log into Penelope System Admin (SA) account.
Click on Billing Setup
Select Edit in the top right corner
Check the “Enable Service Coverage Grouping” checkbox
NOTE: Enabling Service Coverage Grouping will also enable “Limit to Covered Service Units in Events” checkbox on the Service Unit setup page on the System Admin side.
Setting OFF – Does not limit the Service Units that can be selected. If a user selects a Service Unit that is not covered they will be presented with a confirmation box. There is no visual indicator something isn't covered until a user selects and tries to add the Service Unit.
Setting ON – Limits the list to the Service Units that are covered, unless the setting to override this limit is on for the Service Unit and is configured for the Case Service.
See the "Service Unit Grouping" section below for more information.
Using Service Coverage Grouping
What to expect with Service Coverage Grouping when adding a Service File via the Add Service File link on the Case level
The Worker will see two sections in the Service dropdown if there is at least one covered Case Service: Covered and Other.
All Case Services that have a Service Unit that is covered for at least one Case member will display under the Covered section and the rest will be displayed in the Other section.
If a Worker selects any Case Service from the Other section, they will see a confirmation message as no Case member is covered for that Case Service.
The Worker can proceed through this confirmation by selecting Okay.
Users can expect the grouping and confirmation to behave the same way when adding a Service via the Add Service Wizard link on the Case level, via a Pre-Enrollment entry on the Individual level, and via a Referral on the Individual level.
What to expect with Service Coverage Grouping when adding a Group via the Add Service File link on the Case level
If a user selects any Case Service from the Other section and then selects an available Group for that Case Service, after selecting the Finish button the Worker will see the "Case Service is not covered" confirmation message.
If the Case Service is covered, this confirmation message will not appear.
What to expect with Service Coverage Grouping when adding a new Member to a Group Service
When adding an Individual to a Group via the Members tab, if the Individual does not have a policy with coverage for any of the Group's Service Units, the "Case Service is not covered" confirmation message will appear.
If the Individual does have coverage for at least one of the Group's Service Units, no "Case Service is not covered" confirmation message will appear.
Service Unit Grouping
Prerequisite: A Policy will not count as covering a Service unless it has been added to the Billing Sequence on the Service File.
What to expect when booking an Event when “Limit to Covered Service Units in Events” is enabled
On the Book Event page only covered Service Units will appear in the Service Unit selection dropdown.
Select any available Service Unit, click on the Book button, and the Event will be booked with the Service Unit attached.
NOTE: If the Service Unit is covered for the Service File but the Service Unit is not included in any of the policies in the Service File's Billing Sequence then the "Case Service is not covered" confirmation message will appear.
What to expect when booking an Event when “Limit to Covered Service Units in Events” is disabled
On the Book Event page all Service Units will appear in the Service Unit selection dropdown, whether they are covered by a policy under the Service File Billing Sequence or not.
Selecting any Service Units without coverage will prompt the "Case Service is not covered" confirmation message.
Selecting any covered Service Units will not prompt a confirmation message before the user proceeds.
NOTES: This is same behaviour for all Service Units (standard and NDIS), and the same workflow applies for adding a Service Unit from the Cart tab after an Event has been booked. The Worker will still see the "Case Service is not covered" confirmation message when attempting to add a Service Unit without coverage.
Service Coverage Grouping FAQ
Why is the Case Service appearing in the Covered section when I'm selecting from a dropdown even though some participants are not covered or are not covered for the appropriate Service Unit?
A Case Service is considered to be “Covered” when one or more Case member(s) have a policy that covers at least one of the Service Units in that Case Service. If you’re adding a Service File for an Individual who is not covered under any of the policies, but other members of the Individual’s Case are covered, and those members are also being added to the Service File, the Case Service will still show as “Covered”. Additionally, depending on settings, the Individual may be charged FFS for items, for example, if they choose ‘okay’ when presented with the “The selected Service Unit(s) is/are not covered. Do you wish to continue?” warning message, or, if an Individual is covered for a Case Service’s Service Unit but the Group Service does not have that Service Unit added to its list of Service Units.
Why am I allowed to add an Individual to a Group Service who is not covered for the Group’s Service Unit(s)?
The logic is checking that at least one Case member is covered for a Service Unit that is added to the Case Service rather than the Group. Check the Service File’s Case Service to see if the Service Unit has been added at this level.
Why does my Group appear to be covered when the Individual has no policy coverage for the Group Service Units?
You can end up in a situation where someone would be covered for the Case Service, but not covered for the Group as these settings don't check Service Unit coverage at the Group level. An Individual could end up getting a FFS charge for this.
Are there any Group Service limitations?
Group Service Units are not considered during validation. Validation only checks that one Case member is covered for at least one of the Service Units in the Service File. As a result, this functionality may not work for NDIS Groups.
Is Funder type a consideration for the coverage grouping?
No. All funder types are treated the same for coverage grouping.
How does coverage validation work with repeat events?
When selecting Service Units for repeating Service Events, the list of Service Units available can be limited using the “Limit to Covered Service Units in Events” setting. Regardless of this setting, a Service Event series will not be validated for coverage and the worker will get a warning message stating that some events may not be covered for the series; it’s possible that some of the events will not be covered.