Complete Guide to Insurance Coverage Plans in Perfect Hospital Management System

1. How insurance is organised

Insurance configuration has five main parts. Keeping these parts separate makes each agreement easier to understand, reuse and audit.

A plan is reusable. Configure its rules once, then assign the plan to every eligible patient. Patient policies hold membership and policy information; they do not contain individual overrides to the plan's rules.

2. Before you configure a plan

Obtain the written benefit schedule or contract from the provider. For each service group, identify:

• who pays and how much;
• whether the rule applies to an exact service, a category or all eligible services;
• whether it applies to inpatient care, outpatient care or both;
• any deductible, maximum benefit or usage count;
• the period used by each limit;
• required referral, authorisation or claim documents;
• the plan's start and end dates; and
• whether membership must be paid before benefits become active.

Use clear service categories in the hospital catalogue—for example Consultation, Surgery, Dental and Eye Care. A well-organised catalogue makes category-based insurance rules easier to maintain.

3. Add the insurance provider

1. Open Insurance Reconciliations.
2. Select Add Insurance Provider.
3. Enter the provider's name, contact details and status.
4. Add operational details where relevant, including payer ID, claim submission method, processing time and payment terms.
5. Save the provider.

The provider record is the parent of its coverage plans. The provider's deposit field and finance information are separate from the coverage calculation rules.

4. Create an Insurance Coverage Plan

Open the provider and select its Insurance Coverage Plans collection. Add a plan and complete the following fields:

After saving, use the plan's child collections to create Coverage Rules, Coverage Limits and Coverage Requirements. New child records opened from the plan are automatically connected to that plan.

5. Configure coverage rules

A rule answers three questions: what does this rule match, what result does it produce, and when does it apply?

Choose what the rule matches

• Exact target: select one service, drug, laboratory template, radiology template or product. Use this for a special exception such as Procalcitonin.
• Category: cover a group such as Surgery or Consultation.
• Billing mode: restrict the rule to a source such as drug or service.
• General rule: leave the exact target and category empty and use “Any” where the benefit should act as the plan's default.

The exact target field can reference different kinds of billable records. First choose the entity type, then search for the item. The saved reference retains the type, ID and display name, so a laboratory template cannot be confused with a drug or ordinary service that happens to have a similar name.

Choose the coverage outcome

Set context, priority and scope

• Care Setting: Any, Inpatient or Outpatient.
• Admission Required: enable when the rule is only valid on a bill linked to an admission.
• Priority: higher numbers take precedence when several benefit rules match the same line.
• Calculation Scope: Line, Service, Visit or Admission. Scope is especially important for fixed copayments and fixed benefits because it determines whether the amount is applied repeatedly or shared within the selected scope.
• Deductible Applies: disable this for benefits that should not be reduced by the plan's deductible, such as a deliberately deductible-free consultation benefit.

6. Configure deductibles, caps and usage limits

Limits can apply to the whole plan or to one linked coverage rule. Leave the rule blank for a plan-wide limit.

Available periods are Visit, Admission, Calendar Year, Policy Year and Lifetime. Choose the period that matches the contract wording. For example:

• “Maximum $150 each visit” becomes a Monetary Cap of 150 with period Visit.
• “Patient pays the first $200 each policy year” becomes a Deductible of 200 with period Policy Year.
• “Four dental visits per policy year” becomes a Usage Count of 4 linked to the dental coverage rule.

Usage is recorded when a bill is finalised. Pending claims reserve their applicable usage. If covered charges are returned or cancelled, the corresponding usage is recalculated or released. Retrying checkout does not create a second usage record for the same bill.

7. Configure referrals, authorisations and documents

Requirements can apply to the entire plan or only to a linked rule. They can also be restricted to inpatient or outpatient care, or require an admission.

Available requirement types include Referral Code, Authorisation Code, Referral Form, Claim Form, File and Custom Evidence. Use Evidence Field when a custom value is stored in a named bill or policy field.

Evidence should be entered or attached to the patient policy or bill before final approval. The software can recognise authorisation and referral codes, attached forms/files and configured custom evidence.

What happens when evidence is missing?

1. The bill can still be finalised.
2. The software calculates and stores the estimated insurer liability.
3. The claim receives the status Pending Requirements.
4. Applicable deductible, cap and usage values are reserved.
5. The approved insurer liability remains zero, so the amount is not yet treated as an approved insurer debt.
6. After evidence is supplied, authorised staff can approve the coverage from Insurance Reconciliations.
7. If coverage is denied, the reservation is released and the charge remains the patient's responsibility.

8. Assign a plan to a patient

1. Open the patient's record and add an Insurance record.
2. Select the Insurance Coverage Plan. The related provider and plan details are filled from the selected plan.
3. Enter the policy number, policy type and policy-holder details.
4. Set the policy status to Active and enter coverage start and end dates.
5. Enter membership start and end dates when this is a subscription package.
6. Add authorisation information and supporting documents where required.
7. Enable Default Policy if this should be selected automatically when the patient has more than one policy.
8. Save the record.

For coverage to calculate, the patient policy and selected plan must both be active and within their applicable dates.

9. Subscription and package plans

When a plan has a subscription fee, saving the patient's insurance membership creates a normal membership bill linked to that insurance record. The membership bill is marked as excluded from insurance so the plan cannot pay for its own subscription.

If Membership Payment Required is enabled, coverage becomes active only after the membership bill is fully paid or an authorised user marks the subscription as waived. Use the policy's membership start and end dates to control the patient's individual benefit period.

The software does not automatically renew these plans, send renewal reminders or apply grace periods. Create the next membership deliberately after confirming the provider's renewal terms.

10. How an insured bill is calculated

When an insured bill is finalised, the software performs the calculation in this order:

1. Validate the patient policy, plan status, dates and subscription status.
2. Calculate the discounted eligible amount for each bill line.
3. Apply matching exclusions.
4. Select the highest-priority matching benefit rule.
5. Apply usage restrictions and deductible.
6. Calculate the percentage, copayment, fixed benefit or full coverage.
7. Apply rule-specific and plan-wide caps.
8. Round each line to two decimal places and assign any rounding residual to the patient.

Coverage applies to the discounted line charge. In the current version, tax remains patient-paid. A bill line with no matching benefit rule receives no insurer contribution.

Understanding the amounts

• Estimated insurer liability: what the insurer would owe if all requirements are approved.
• Approved insurer liability: the amount currently approved for reconciliation. This is zero while requirements are pending or after denial.
• Patient liability: the remaining net bill amount after approved insurer liability.
• Insurer balance: approved insurer liability minus payments already recorded from the third party.

The bill displays the patient/insurer split and an explanation for each item. A calculation snapshot is saved with the finalised bill, including matched rules, exclusions, limits, deductible and requirement results.

11. Approve requirements and reconcile insurer payments

1. Open Insurance Reconciliations and select the provider.
2. Review bills marked Pending Requirements and confirm that all required evidence has been supplied.
3. Approve the coverage to activate the estimated insurer liability, or deny it to leave the patient responsible and release reserved usage.
4. Select one or more bills with an outstanding approved insurer balance.
5. Record the amount received from the provider.

Partial payments are supported. The outstanding amount is always calculated as:

approved insurer liability − payments received from the third party

The software prevents reconciliation above the insurer's outstanding balance. Reconcile against the provider's actual remittance or claim schedule, not merely the original estimate.

12. Worked configuration examples

Example A: Government 90/10 plan with an inpatient exclusion

Agreement: The insurer pays 90% of eligible charges and the patient pays 10%. Malaria testing is covered, but Procalcitonin is not covered for admitted patients. Referral and claim evidence are required.

• Create a general Percentage Coverage rule with value 90 and priority 10.
• Create an exact Malaria Test Percentage Coverage rule with value 90 and a higher priority, such as 500.
• Create an exact Procalcitonin Excluded rule with Inpatient care, Admission Required and priority 1000.
• Add Referral Code, Referral Form and Claim Form requirements.
• Add an inpatient Authorisation Code requirement if admission coverage requires approval.

For an eligible $100 outpatient line, the estimated split is $90 insurer and $10 patient. An inpatient Procalcitonin line remains entirely patient-paid because the exclusion overrides the general 90% rule.

Example B: GlobalCare Basic $800 annual package

Agreement: The patient pays $800 for one year, consultation is free, drugs receive 80% coverage and surgery receives 80% coverage.

• Set Subscription Fee to 800, Duration to 12 months and enable Membership Payment Required.
• Create a Full Coverage rule for Consultation.
• Create an 80% Percentage Coverage rule for drugs.
• Create an 80% Percentage Coverage rule for the Surgery category.
• Assign the plan to the patient and pay or waive the generated membership bill.

A $50 consultation has no patient contribution after approval. A $1,000 eligible surgery produces $800 estimated insurer liability and $200 patient liability, before any applicable deductible or cap.

Example C: Full coverage with a $150 per-visit cap

Agreement: Eligible charges are fully covered, but the organisation pays no more than $150 per visit.

• Create a general Full Coverage rule.
• Create a plan-wide Monetary Cap of 150 with period Visit.

If eligible services total $220 during one visit, the insurer pays $150 and the patient pays $70. A new visit receives a new $150 allowance.

Example D: Annual deductible followed by 90% coverage

Agreement: The patient pays the first $200 of eligible costs each policy year, then the insurer pays 90%.

• Create a general Percentage Coverage rule with value 90 and leave Deductible Applies enabled.
• Create a plan-wide Deductible of 200 with period Policy Year.

Eligible bills first consume the remaining deductible. After the deductible has been satisfied, the 90/10 rule applies to the remaining eligible amount for that policy year.

Example E: Four dental visits per year

Create a dental coverage rule, then create a Usage Count limit of 4 with period Policy Year and link the limit to that dental rule. After four covered usages in the period, further matching charges receive no insurer contribution until a new policy year begins.

13. Editing plans and protecting historical bills

Changes to a plan take effect for future and unfinalised bills. Finalised bills retain their saved calculation snapshot so historical patient and insurer amounts remain explainable even after a rule is changed.

For major contract changes, consider creating a clearly named new plan with new effective dates instead of heavily rewriting a plan that many patients already use. This makes enrolment and reporting easier for administrators.

14. Common problems and checks

15. Recommended setup checklist

• Create and verify the provider.
• Create the plan with correct effective and subscription dates.
• Add one clear default benefit only when the contract genuinely has a default.
• Add exact or category exceptions with higher priorities.
• Add exclusions for every explicitly non-covered service.
• Add deductibles, caps and usage counts using the contract's exact period.
• Add referral, authorisation and document requirements.
• Test the plan with sample bills before assigning it widely.
• Confirm every test bill explains the selected rule and patient/insurer split.
• Train finance staff to approve evidence before insurer reconciliation.

For related workflows, see Adding patient insurance information and Billing and insurance reconciliation.