Before Using a Benefit Plan

You are here: Benefits > Before Using a Benefit Plan

Before Using a Benefit Plan

Before a benefit plan can be used to process claims, you must set up the basic blocks of information and use them to build a plan. Information on these tasks is provided in this documentation.

Setup Tasks

The following information used to build benefit plan must be set up by the appropriate personnel.

Before you can begin adding, have the following information set up:

Line of business and its customer.
Benefit plan type, option, and status (available in system lists).

Before you can complete adding, have the following information set up:

Provider networks, for Medicaid Management Information System (MMIS) plans.
Maps that define, for MMIS plans, the services that
- are covered or not covered.
- require authorization when covered under this benefit plan.
- are limited in terms of dollar amount or units of service.

Note: Additional maps are required for managed care plans, if that functionality is available.

Exception codes used.
System lists that determine, for MMIS plans, what category of eligibility codes or nursing facility span type codes are used to bypass the posting of plan limit exception codes. If managed care functionality is available, also set up the system lists that determine the cutback rule types for MMIS plans. For pharmacy plans, a list that provides exemption override options needs to be set up in OS+.
For pharmacy plans, a business rule needs to be set up in OS+ for the hierarchy of generic code types that determines which drug category to check first for a particular drug code to determine if it will be covered or not.
If this is a capitation or case management plan,
- Procedure codes used to generate claims for capitation payments to providers for current enrollment span
- Map that defines the member cohort for which the rate capitation or case management fee applies, if applicable.

Build Tasks

Before the plan can be used to process claims, you must build the plan using the Plan Navigator page to:

Identify the plan. (Before saving the benefit plan for the first time, complete at a minimum the Plan Navigator header and Benefit Plan - Main panels.)
If this is an MMIS plan, associate provider networks.
If this is managed care plan or a plan that uses primary care physicians, provide capitation or case management processing instructions.
For most other plans, other than capitation or case management plans, complete coverage, service authorization, and plan limits information.
Complete the remaining components only if they are necessary for the type of plan you are adding.

In addition,

You must provide the processing sequence (the rank) for all benefit plans used by a customer on the LOB/Benefit Plan Hierarchy page.
You must define the criteria that must be met in order to assign a member to a particular benefit plan by creating appropriate Member Control Table (MCT) or Pharmacy Member Control (PMC) map definitions.